Nclex Questions Chap 23 38

9/22/2020 NCLEX-Style Review Questions
Quiz Stats
Name: Cezhille Battad Quiz completed in: 5.23 mins

Date: 2020-9-22 Time: 04:12:11 Questions answered: 38
Number correct: 38 (100%)
Answer Key
QUESTION 1: Which term refers to lung tissue that has become more solid in nature as a
result of a collapse of alveoli or an infectious process?
Your Response: Correct!
Correct Response: Consolidation
Explanation: Consolidation occurs during an infectious process such as pneumonia.

Atelectasis refers to the collapse or airless condition of the alveoli caused by
hypoventilation, obstruction to the airways, or compression. Bronchiectasis
refers to the chronic dilation of a bronchi or bronchi in which the dilated
airway becomes saccular and a medium for chronic infection. Empyema refers
to accumulation of purulent material in the pleural space.
QUESTION 2: Which community-acquired pneumonia demonstrates the highest occurrence

during summer and fall?
Correct Response: Legionnaires disease
Explanation: Legionnaires disease accounts for 15% of community-acquired pneumonias; it

occurs mainly in summer and fall. Streptococcal and viral pneumonias
demonstrate the highest occurrence during the winter months. Mycoplasmal
pneumonia demonstrates the highest occurrence in fall and early winter.
QUESTION 3: When interpreting the results of a Mantoux test, the nurse explains to the
client that a reaction occurs when the intradermal injection site shows
Correct Response: redness and induration.
Explanation: The injection site is inspected for redness and palpated for hardening.
Drainage at the injection site does not indicate a reaction to the tubercle
bacillus. Sloughing of tissue at the injection site does not indicate a reaction
to the tubercle bacillus. Bruising of tissue at the site may occur from the
injection but does not indicate a reaction to the tubercle bacillus.
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QUESTION 4: Which action by the nurse is most appropriate when the client demonstrates
subcutaneous emphysema along the suture line or chest dressing 2 hours after
chest surgery?
Correct Response: Record the observation
Explanation: Subcutaneous emphysema occurs after chest surgery as the air that is located
within the pleural cavity is expelled through the tissue opening created by
the surgical procedure. Subcutaneous emphysema is a typical finding in
clients after chest surgery. Subcutaneous emphysema is absorbed by the body
spontaneously after the underlying leak is treated or halted. Subcutaneous
emphysema results from air entering the tissue planes.
QUESTION 5: Which type of lung cancer is characterized as fast growing and tends to arise
peripherally?
Correct Response: Large cell carcinoma
Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally.
Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and
usually grows slowly. Adenocarcinoma presents as peripheral masses or
nodules and often metastasizes. Squamous cell carcinoma arises from the
bronchial epithelium and is more centrally located.
QUESTION 6: Which type of lung cancer is the most prevalent among both men and women?
Correct Response: Adenocarcinoma
Explanation: Adenocarcinoma is most prevalent in both men and women and presents more
peripherally as masses or nodules and often metastasizes. Large cell
carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous
cell carcinoma is more centrally located and arises more commonly in the
segmental and subsegmental bronchi in response to repetitive carcinogenic
exposure. Small cell carcinomas arise primarily as proximal lesions, but may
arise in any part of the tracheobronchial tree.
QUESTION 7: Which should a nurse encourage in clients who are at the risk of
pneumococcal and influenza infections?
Correct Response: Receiving vaccinations
Explanation: Identifying clients who are at risk for pneumonia provides a means to practice
preventive nursing care. The nurse encourages clients at risk of pneumococcal
and influenza infections to receive vaccinations against these infections. The

nurse should encourage early mobilization as indicated through agency
protocol, administer prescribed opioids and sedatives as indicated, and teach
or reinforce appropriate technique for incentive spirometry to prevent
atelectasis.
QUESTION 8: Which technique does the nurse suggest to a client with pleurisy while
teaching about splinting the chest wall?
Correct Response: Turn onto the affected side.
Explanation: The nurse teaches the client to splint the chest wall by turning onto the
affected side. The nurse also instructs the client to take analgesic
medications as prescribed and to use heat or cold applications to manage
pain with inspiration. The client can also splint the chest wall with a pillow
when coughing.
QUESTION 9: For a client with pleural effusion, what does chest percussion over the
involved area reveal?
Correct Response: Dullness over the involved area
Explanation: Chest percussion reveals dullness over the involved area. The nurse may note
diminished or absent breath sounds over the involved area when auscultating
the lungs and may also hear a friction rub. Chest radiography and computed
tomography show fluid in the involved area.
QUESTION 10: What dietary recommendations should a nurse provide a client with a lung
abscess?
Correct Response: A diet rich in protein
Explanation: For a client with lung abscess, a diet rich in protein and calories is integral
because chronic infection is associated with a catabolic state. A
carbohydrate-dense diet or diets with limited fat are not advisable for a
client with lung abscess.
QUESTION 11: Which interventions does a nurse implement for clients with empyema?
Correct Response: Encourage breathing exercises
Explanation: The nurse teaches the client with empyema to do breathing exercises as
prescribed. The nurse should institute droplet precautions and isolate
suspected and clients with confirmed influenza in private rooms or place

suspected and confirmed clients together. The nurse does not allow visitors
with symptoms of respiratory infection to visit the hospital to prevent
outbreaks of influenza from occurring in health care settings.
QUESTION 12: A physician stated to the nurse that the client has fluid in the pleural space
and will need a thoracentesis. The nurse expects the physician to document
this fluid as
Correct Response: pleural effusion.
Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A
pneumothorax is air in the pleural space. A hemothorax is blood within the
pleural space. Consolidation is lung tissue that has become more solid in
nature as a result of the collapse of alveoli or an infectious process.
QUESTION 13: Which type of pneumonia has the highest incidence in clients with AIDS and
clients receiving immunosuppressive therapy for cancer?
Correct Response: Pneumocystis
Explanation: Pneumocystis pneumonia incidence is greatest in clients with AIDS and clients
receiving immunosuppressive therapy for cancer, organ transplanation, and
other disorders.
QUESTION 14: Which is a true statement regarding severe acute respiratory syndrome
(SARS)?
Correct Response: It is most contagious during the second week of illness.
Explanation: Based on available information, SARS is most likely to be contagious only

when symptoms are present, and clients are most contagious during the
second week of illness. Diarrhea and hyperthermia may occur with SARS.
Respiratory droplets spread the SARS virus when an infected person coughs or
sneezes.
QUESTION 15: Class 1 with regard to TB indicates
Correct Response: exposure and no evidence of infection.
Explanation: Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no

infection. Class 2 is a latent infection with no disease. Class 4 is disease, but
not clinically active.
QUESTION 16: Resistance to a first-line antituberculotic agent in a client who has not

received previous treatment is referred to as
Correct Response: primary drug resistance.
Explanation: Primary drug resistance refers to resistance to one of the first-line

antituberculotic agents in people who have not received previous treatment.
Secondary or acquired drug resistance is resistance to one or more
antituberculotic agents in clients undergoing therapy. Multidrug resistance is
resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug
resistance is not a type of resistance.
QUESTION 17: Which vitamin is usually administered with isoniazid (INH) to prevent INH-
associated peripheral neuropathy?
Correct Response: Vitamin B6
Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-

associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
QUESTION 18: Which is a key characteristic of pleurisy?
Correct Response: Pain
Explanation: The key characteristic of pleuritic pain is its relationship to respiratory

movement. Taking a deep breath, coughing, or sneezing worsens the pain.
QUESTION 19: Arterial blood gas analysis would reveal which value related to acute
respiratory failure?
Correct Response: pH 7.28
Explanation: Acute respiratory failure is defined as a decrease in arterial oxygen tension

(PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon
dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an
arterial pH less than 7.35.
QUESTION 20: Which would be least likely to contribute to a case of hospital-acquired

pneumonia?
Correct Response: A nurse washes her hands before beginning client care.
Explanation: HAP occurs when at least one of three conditions exists: host defenses are
impaired, inoculums of organisms reach the lower respiratory tract and
overwhelm the host's defenses, or a highly virulent organism is present.
QUESTION 21: The nursing instructor is teaching students about types of lung cancer. Which
type of lung cancer is characterized as fast growing and can arise
peripherally?
Correct Response: Large cell carcinoma
Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally.
Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and
usually grows slowly. Adenocarcinoma presents as peripheral masses or
nodules and often metastasizes. Squamous cell carcinoma arises from the
bronchial epithelium and is more centrally located.
QUESTION 22: During a community health fair, a nurse is teaching a group of seniors about
promoting health and preventing infection. Which intervention would best
promote infection prevention for senior citizens who are at risk of
pneumococcal and influenza infections?
Correct Response: Receive vaccinations
Explanation: Identifying clients who are at risk for pneumonia provides a means to practice
preventive nursing care. The nurse encourages clients at risk of pneumococcal
and influenza infections to receive vaccinations against these infections.
QUESTION 23: Which comfort technique does a nurse teach to a client with pleurisy to assist
with splinting the chest wall?
Correct Response: Turn onto the affected side
Explanation: The nurse teaches the client to splint the chest wall by turning onto the
affected side in order to reduce the stretching of the pleurae and decrease
pain.
QUESTION 24: An emergency room nurse is assessing a client who is complaining of dyspnea.
Which sign would indicate the presence of a pleural effusion?
Correct Response: Decreased chest wall excursion upon palpation
Explanation: Symptoms of pleural effusion are shortness of breath, pain, assumption of a

position that decreases pain, absent breath sounds, decreased fremitus, a
dull, flat sound upon percussion, and decreased chest wall excursion. The
nurse may also hear a friction rub. Chest radiography and computed
tomography show fluid in the involved area.
QUESTION 25: A nurse is preparing dietary recommendations for a client with a lung abscess.
Which statement would be included in the plan of care?
Correct Response: “You must consume a diet rich in protein, such as chicken, fish, and beans.”
Explanation: The nurse encourages a client with a lung abscess to eat a diet that is high in
protein and calories in order to ensure proper nutritional intake. A
carbohydrate-dense diet or diets with limited fats are not advisable for a
client with a lung abscess.
QUESTION 26: Which intervention does a nurse implement for clients with empyema?
Correct Response: Encourage breathing exercises
Explanation: The nurse instructs the client in lung-expanding breathing exercises to restore
normal respiratory function.
QUESTION 27: A nurse is caring for a client after a thoracentesis. Which sign, if noted in the
client, should be reported to the physician immediately?
Correct Response: “Client is becoming agitated and complains of pleuritic pain.”
Explanation: After a thoracentesis, the nurse monitors the client for pneumothorax or
recurrence of pleural effusion. Signs and symptoms associated with
pneumothorax depend on its size and cause. Pain is usually sudden and may
be pleuritic. The client may have only minimal respiratory distress, with
slight chest discomfort and tachypnea, and a small simple or uncomplicated
pneumothorax. As the pneumothorax enlarges, the client may become
anxious and develop dyspnea with increased use of the accessory muscles.
QUESTION 28: A nurse reading a chart notes that the client had a Mantoux skin test result
with no induration and a 1-mm area of ecchymosis. How does the nurse
interpret this result?
Correct Response: Negative
Explanation: The size of the induration determines the significance of the reaction. A
reaction 0–4 mm is not considered significant. A reaction ≥5 mm may be
significant in people who are considered to be at risk. An induration ≥10 mm
or greater is usually considered significant in people who have normal or
mildly impaired immunity.
QUESTION 29: The nurse caring for a client with tuberculosis anticipates administering
which vitamin with isoniazid (INH) to prevent INH-associated peripheral
neuropathy?
Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-

associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
QUESTION 30: A nurse assesses arterial blood gas results for a patient in acute respiratory
failure (ARF). Which results are consistent with this disorder?
Correct Response: pH 7.28, PaO2 50 mm Hg
Explanation: ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60
mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension
(PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
QUESTION 31: A client suspected of developing acute respiratory distress syndrome (ARDS) is
experiencing anxiety and agitation due to increasing hypoxemia and dyspnea.
A nurse would implement which intervention to improve oxygenation and
provide comfort for the client?
Correct Response: Position the client in the prone position
Explanation: The patient is extremely anxious and agitated because of the increasing
hypoxemia and dyspnea. It is important to reduce the patient’s anxiety
because anxiety increases oxygen expenditure. Oxygenation in patients with
ARDS is sometimes improved in the prone position. Rest is essential to limit
oxygen consumption and reduce oxygen needs.
QUESTION 32: A mechanically ventilated client is receiving a combination of atracurium and

the opioid analgesic morphine. The nurse monitors the client for which
potential complication?
Correct Response: Venous thromboemboli
Explanation: Neuromuscular blockers predispose the client to venous thromboemboli

(VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown.
Nursing assessment is essential to minimize the complications related to
neuromuscular blockade. The client may have discomfort or pain but be
unable to communicate these sensations.
QUESTION 33: The nurse is providing discharge instructions to a client with pulmonary
sarcoidosis. The nurse concludes that the client understands the information
if the client correctly mentions which early sign of exacerbation?
Correct Response: Shortness of breath
Explanation: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea,
cough, hemoptysis, and congestion. Generalized symptoms include anorexia,
fatigue, and weight loss.
QUESTION 34: A client admitted to the hospital following a motor vehicle crash has suffered
a flail chest. The nurse assesses the client for what most common clinical
manifestation of flail chest?
Correct Response: Paradoxical chest movement
Explanation: During inspiration, as the chest expands, the detached part of the rib
segment (flail segment) moves in a paradoxical manner (pendelluft
movement) in that it is pulled inward during inspiration, reducing the amount
of air that can be drawn into the lungs. Upon expiration, because the
intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges
outward, impairing the client’s ability to exhale. The mediastinum then shifts
back to the affected side. This paradoxical action results in increased dead
space, a reduction in alveolar ventilation, and decreased compliance.
QUESTION 35: The nurse is assessing a client who, after an extensive surgical procedure, is
at risk for developing acute respiratory distress syndrome (ARDS). The nurse
assesses for which most common early sign of ARDS?
Correct Response: Rapid onset of severe dyspnea
Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that
usually occurs less than 72 hours after the precipitating event.
QUESTION 36: A client involved in a motor vehicle crash suffered a blunt injury to the chest
wall and was brought to the emergency department. The nurse assesses the
client for which clinical manifestation that would indicate the presence of a
pneumothorax?
Correct Response: Sucking sound at the site of injury
Explanation: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a

wound in the chest wall is large enough to allow air to pass freely in and out
of the thoracic cavity with each attempted respiration. Because the rush of
air through the wound in the chest wall produces a sucking sound, such
injuries are termed "sucking chest wounds."
QUESTION 37: A client diagnosed with acute respiratory distress syndrome (ARDS) is restless
and has a low oxygen saturation level. If the client’s condition does not
improve and the oxygen saturation level continues to decrease, what
procedure will the nurse expect to assist with in order to help the client
breathe more easily?
Correct Response: Intubate the client and control breathing with mechanical ventilation
Explanation: A client with ARDS may need mechanical ventilation to assist with breathing
while the underlying cause of the pulmonary edema is corrected. The other
options are not appropriate.
QUESTION 38: The nurse is interpreting blood gases for a client with acute respiratory
distress syndrome (ARDS). Which set of blood gas values indicates respiratory
acidosis?
Correct Response: pH 7.25, PaCO2 48, HCO3 24
Explanation: pH <7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2
38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30
indicate respiratory alkalosis; and pH 7.49, PaCO2 34, HCO3 25 indicate
respiratory alkalosis.
Quiz Stats

Answer Key
QUESTION 1: Which statement describes emphysema?
Correct Response: A disease of the airways characterized by destruction of the walls of

overdistended alveoli
Explanation: Emphysema is a category of COPD. Asthma has a clinical outcome of airflow

obstruction. Bronchitis includes the presence of cough and sputum production
for at least a combined total of 2 to 3 months in each of two consecutive
years. Bronchiectasis is a condition of chronic dilatation of a bronchus or
bronchi.
QUESTION 2: Which is the most important risk factor for development of chronic
obstructive pulmonary disease (COPD)?
Correct Response: Cigarette smoking
Explanation: Pipe, cigar, and other types of tobacco smoking are also risk factors for COPD.
Although risk factors, neither occupational exposure nor air pollution is the
most important risk factor for development of COPD. Genetic abnormalities
are also a risk factor, but again, not the most important one.
QUESTION 3: Which type of chest configuration is typical of a client with COPD?
Correct Response: Barrel chest
Explanation: In clients with COPD who have a primary emphysematous component, chronic
hyperinflation leads to the “barrel chest” thorax configuration. This
configuration results from a more fixed position of the ribs in the inspiratory
position (due to hyperinflation) and from loss of lung elasticity. Pigeon chest
results from a displaced sternum. Flail chest results when the ribs are
fractured. Funnel chest occurs when there is a depression in the lower
portion of the sternum; it is associated with Marfan syndrome or rickets.
QUESTION 4: In which grade of COPD is the forced expiratory volume (FEV) less than 30%?
Correct Response: III
Explanation: Clients with grade III COPD demonstrate an FEV1 less than 30–50% predicted,
with respiratory failure or clinical signs of right heart failure. Grade I is mild
COPD, with an FEV1 ≥80% predicted. Clients with grade II COPD demonstrate
an FEV1 of 50–80% predicted. Grade IV is characterized by FEV1 less 30%
predicted.
QUESTION 5: Which terms means an increase in the red blood cell concentration in the
blood?
Correct Response: Polycythemia
Explanation: Polycythemia is an increase in the red blood cell concentration in the blood.
Emphysema is a disease of the airways characterized by destruction of the
walls of overdistended alveoli. Asthma is a disease with multiple precipitating
mechanisms resulting in a common clinical outcome of reversible airflow
obstruction. Bronchitis is a disease of the airways defined as the presence of
cough and sputum production for a certain period of time.
QUESTION 6: Which is the strongest predisposing factor for asthma?
Correct Response: Allergy
Explanation: Allergy is the strongest predisposing factor for asthma.
QUESTION 7: Which medication is contraindicated in acute asthma exacerbations?
Correct Response: Cromolyn sodium
Explanation: Cromolyn sodium is contraindicated in clients with acute asthma

exacerbation.
QUESTION 8: As status asthmaticus worsens, the nurse would expect which acid-base
imbalance?
Correct Response: Respiratory acidosis
Explanation: As status asthmaticus worsens, the PaCO2 increases and the pH decreases,
reflecting respiratory acidosis.
QUESTION 9: Which diagnostic test is the most accurate in assessing acute airway
obstruction?
Correct Response: Pulmonary function studies
Explanation: Pulmonary function studies are the most accurate means of assessing acute
airway obstruction. ABGs, pulse oximetry, and chest x-ray are not the most
accurate diagnostics for an airway obstruction.
QUESTION 10: Cystic fibrosis (CF) is diagnosed by clinical signs and symptoms in addition to
which test?
Correct Response: Sweat chloride concentration
Explanation: Diagnosis of CF is based on an elevated sweat chloride concentration,

together with clinical signs and symptoms consistent with the disease.
QUESTION 11: Which symptoms are considered primary symptoms of COPD?
Correct Response: Cough
Explanation: COPD is characterized by three primary symptoms: cough, sputum production,

and dyspnea upon exertion. Weight loss is common with COPD.
QUESTION 12: Which exposure acts as a risk factor for and accounts for the majority of
cases of chronic obstructive pulmonary disease (COPD)?
Correct Response: Exposure to tobacco smoke
Explanation: Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD
cases. Occupational exposure, passive smoking, and ambient air pollution are
risk factors but do not account for the majority.
QUESTION 13: The classification of grade I COPD is defined as
Correct Response: mild COPD.
Explanation: Grade I is mild COPD. Grade II is moderate COPD. Grade III is severe COPD.
Grade IV is very severe COPD.
QUESTION 14: Which drug is second-line pharmacotherapy for smoking abstinence?
Correct Response: Clonidine
Explanation: Second-line pharmacotherapy includes the antihypertensive agent clonidine.

However, its use is limited by its side effects. First-line therapy includes
nicotine gum, nortriptyline, and buproprion SR.
QUESTION 15: Which statement describes emphysema?
Correct Response: A disease of the airways characterized by destruction of the walls of

overdistended alveoli
Explanation: Emphysema is a category of chronic obstructive pulmonary disease (COPD). In

emphysema, impaired oxygen and carbon dioxide exchange results from
destruction of the walls of overdistended alveoli. Emphysema is a pathologic
term that describes an abnormal distention of the airspaces beyond the
terminal bronchioles and destruction of the walls of alveoli; a chronic
inflammatory response may induce disruption of the parenchymal tissues.
Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the
presence of cough and sputum production for at least a combined total of 2
to 3 months in each of two consecutive years. Bronchiectasis is a condition of
chronic dilatation of a bronchus or bronchi.
QUESTION 16: Which is the most important risk factor for development of COPD?
Correct Response: Cigarette smoking
Explanation: Risk factors for COPD include environmental exposures and host factors. The
most important environmental risk factor for COPD worldwide is cigarette
smoking. A dose-response relationship exists between the intensity of smoking
(pack-year history) and the decline in pulmonary function. Other
environmental risk factors include smoking pipes, cigars, and other types of
tobacco. Passive smoking (i.e., second-hand smoke) also contributes to
respiratory symptoms and COPD. Air pollution and genetic abnormalities are
risk factors for development of COPD, but neither is the most important.
QUESTION 17: In which grade of COPD is the forced expiratory volume in 1 second (FEV1)
less than 30% predicted?

Correct Response: IV
Explanation: COPD is classified into four grades depending on the severity measured by
pulmonary function tests. However, pulmonary function is not the only way to
assess or classify COPD; pulmonary function is evaluated in conjunction with
symptoms, health status impairment, and the potential for exacerbations.
Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate):
FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC
<70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70%
and FEV1 <30% predicted.
QUESTION 18: In COPD, the body attempts to improve oxygen-carrying capacity by

increasing the amount of red blood cells. Which term refers to this process?
Correct Response: Polycythemia
Explanation: Polycythemia is an increase in the red blood cell concentration in the blood.
In COPD, the body attempts to improve oxygen-carrying capacity by producing
increasing amounts of red blood cells.
QUESTION 19: A client is being admitted to the medical–surgical unit for the treatment of an
exacerbation of acute asthma. Which medication is contraindicated in the
treatment of asthma exacerbations?
Correct Response: Cromolyn sodium
Explanation: Cromolyn sodium is contraindicated in clients with acute asthma

exacerbation. Indications for cromolyn sodium are long-term prevention of
symptoms in mild, persistent asthma; it may modify inflammation. Cromolyn
sodium is also a preventive treatment before exposure to exercise or a known
allergen. Albuterol, levalbuterol HFA, and ipratropium can be used to relieve
acute symptoms.
QUESTION 20: Which diagnostic test is most accurate in assessing acute airway obstruction?
Correct Response: Pulmonary function studies
Explanation: Pulmonary function studies are used to help confirm the diagnosis of COPD,
determine disease severity, and monitor disease progression. ABGs and pulse
oximetry are not the most accurate diagnostics for an airway obstruction.
Spirometry is used to evaluate airflow obstruction, which is determined by
the ratio of FEV1 to forced vital capacity (FVC).
QUESTION 21: A client newly diagnosed with COPD tells the nurse, “I can’t believe I have
COPD; I only had a cough. Are there other symptoms I should know about”?
Which is the best response by the nurse?
Correct Response: “Other symptoms you may develop are shortness of breath upon exertion and
sputum production.”
Explanation: COPD is characterized by three primary symptoms: cough, sputum production,

and dyspnea upon exertion. Clients with COPD are at risk for respiratory
insufficiency and respiratory infections, which in turn increase the risk of
acute and chronic respiratory failure. Weight loss is common with COPD.
QUESTION 22: Which exposure accounts for most cases of COPD?
Correct Response: Exposure to tobacco smoke
Explanation: Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD
cases. Occupational exposure, passive smoking, and ambient air pollution are
risk factors, but they do not account for most cases.
QUESTION 23: The nurse is reviewing first-line pharmacotherapy for smoking abstinence
with a client diagnosed with COPD. The nurse correctly includes which
medications? Select all that apply.
Correct Response: Nicotine gum

Bupropion SR
Bupropion SR
Explanation: First-line therapy includes nicotine gum and Bupropion SR. Second-line
pharmacotherapy includes the antihypertensive agent clonidine. However, the
use of clonidine is limited by its side effects. Varenicline, a nicotinic
acetylcholine receptor partial agonist, may also assist in smoking cessation.
QUESTION 24: Why would a client with COPD report feeling fatigued? Select all that apply.
Correct Response: Lung function gradually decreases over time in clients with COPD.
The client is using all expendable energy just to breathe.
Explanation: The client is using all expendable energy just to breathe. Lung function, not
muscle function, gradually decreases over time in clients with COPD. In a
client with COPD, fatigue and a feeling of exhaustion stem directly from the
disease, not from activity level.
QUESTION 25: In which statements regarding medications taken by a client diagnosed with
COPD do the the drug name and the drug category correctly match? Select all
that apply.
Correct Response: Ciprofloxacin is an antibiotic.

Albuterol is a bronchodilator.
Prednisone is a corticosteroid.
Explanation: Theophylline, albuterol, and atropine are bronchodilators. Dexamethasone

and prednisone are corticosteroids. Amoxicillin, ciprofloxacin, and
cotrimoxazole are antibiotics. All of these drugs could be prescribed to a
client with COPD.
QUESTION 26: A client presents to the ED experiencing symptoms of COPD exacerbation. The
nurse understands that goals of therapy should be achieved to improve the
client’s condition. Which statements reflect therapy goals? Select all that
apply.
Correct Response: Provide long-term support for medical management.

Provide medical support for the current exacerbation.
Return the client to their original functioning abilities.
Treat the underlying cause of the event.
Explanation: The goal is to have a stable client with COPD leading the most productive life
possible. COPD cannot necessarily be cured, but it can be managed so that
the client can live a reasonably normal life. With adequate management,
clients should not have to give up their usual activities.
QUESTION 27: Which measure may increase complications for a client with COPD?
Correct Response: Increased oxygen supply
Explanation: Administering too much oxygen can result in the retention of carbon dioxide.
Clients with alveolar hypoventilation cannot increase ventilation to adjust for
this increased load, and hypercapnia occurs. All the other measures aim to
prevent complications.
QUESTION 28: Which statement is true about both lung transplant and bullectomy?
Correct Response: Both aim to improve the overall quality of life of a client with COPD.
Explanation: Treatments for COPD are aimed more at treating the symptoms and
preventing complications, thereby improving the overall quality of life of a
client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed
at treating end-stage emphysema and bullectomy is used to treat clients with

bullous emphysema.
QUESTION 29: A nurse is caring for a client with COPD. While reviewing breathing exercises,
the nurse instructs the client to breathe in slowly through the nose, taking in
a normal breath. Then the nurse asks the client to pucker his lips as if
preparing to whistle. Finally, the client is told to exhale slowly and gently
through the puckered lips. The nurse teaches the client this breathing
exercise to accomplish which goals? Select all that apply.
Correct Response: Control the rate and depth of respirations

Prevent airway collapse
Release air trapped in the lungs
Explanation: The nurse is teaching the client the technique of pursed-lip breathing. It
helps slow expiration, prevents collapse of the airways, releases air trapped
in the lungs, and helps the client control the rate and depth of respirations.
This helps clients relax and get control of dyspnea and reduces the feelings of
panic they may experience. Diaphragmatic breathing strengthens the
diaphragm during breathing. In inspiratory muscle training, the client will be
instructed to inhale against a set resistance for a prescribed amount of time
every day in order to condition the inspiratory muscles.
QUESTION 30: A client diagnosed with asthma is preparing for discharge. The nurse is
educating the client on the proper use of a peak flow meter. The nurse
instructs the client to complete which action?
Correct Response: If coughing occurs during the procedure, repeat it.
Explanation: Steps for using the peak flow meter correctly include (1) moving the indicator
to the bottom of the numbered scale; (2) standing up; (3) taking a deep
breath and filling the lungs completely; (4) placing the mouthpiece in the
mouth and closing the lips around it; (5) blowing out hard and fast with a
single blow; and (6) recording the number achieved on the indicator. If the
client coughs or a mistake is made in the process, repeat the procedure. Peak
flow readings should be taken during an asthma attack.
QUESTION 31: A client with bronchiectasis is admitted to the nursing unit. The primary
focus of nursing care for this client includes
Correct Response: implementing measures to clear pulmonary secretions.
Explanation: Nursing management focuses on alleviating symptoms and helping clients

clear pulmonary secretions. Although teaching the family how to perform
postural drainage and instructing the client on the signs of respiratory
infection are important, they are not the nurse’s primary focus. The presence
of a large amount of mucus may decrease the client’s appetite and result in
inadequate dietary intake; therefore, the client’s nutritional status is
assessed and strategies are implemented to ensure an adequate diet.
QUESTION 32: The nurse is assigned the care of a 30-year-old client diagnosed with cystic
fibrosis (CF). Which nursing intervention will be included in the client’s care
plan?
Correct Response: Performing chest physiotherapy as ordered
Explanation: Nursing care includes helping clients manage pulmonary symptoms and
prevent complications. Specific measures include strategies that promote
removal of pulmonary secretions, chest physiotherapy, and breathing
exercises. In addition, the nurse emphasizes the importance of an adequate
fluid and dietary intake to promote removal of secretions and to ensure an
adequate nutritional status. Clients with CF also experience increased salt
content in sweat gland secretions; thus it is important to ensure the client
consumes a diet that contains adequate amounts of sodium. As the disease
progresses, the client will develop increasing hypoxemia. In this situation,
preferences for end-of-life care should be discussed, documented, and
honored; however, there is no indication that the client is terminally ill.
QUESTION 33: The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions
with a client. Which statement by the client indicates the need for further
instruction?
Correct Response: “I can’t use a spacer or holding chamber with the MDI.”
Explanation: The client can use a spacer or a holding chamber to facilitate the ease of
medication administration. The remaining client statements are accurate and
indicate the client understands how to use the MDI correctly.
QUESTION 34: The nurse is caring for a patient with COPD. The patient is receiving oxygen
therapy via nasal cannula. The nurse understands that the goal of oxygen
therapy is to maintain the patient’s SaO2 level at or above what percent?
Correct Response: 90%
Explanation: The goal of supplemental oxygen therapy is to increase the baseline resting
partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level
and arterial oxygen saturation (SaO2) to at least 90%.
QUESTION 35: A client is receiving theophylline for long-term control and prevention of
asthma symptoms. Client education related to this medication will include
Correct Response: the importance of blood tests to monitor serum concentrations.
Explanation: The nurse should inform clients about the importance of blood tests to
monitor serum concentration. The therapeutic range of theophylline is
between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.
QUESTION 36: A client is being treated in the ED for respiratory distress coupled with
pneumonia. The client has no medical history. However, the client works in a
coal mine and smokes 10 cigarettes a day. The nurse anticipates which
order based on the client's immediate needs?
Correct Response: Administration of antibiotics
Explanation: Antibiotics are administered to treat respiratory tract infections. Chronic

bronchitis is inflammation of the bronchi caused by irritants or infection.
Hence, smoking cessation and avoiding pollutants are necessary to slow the
accelerated decline of the lung tissue. However, the immediate priority in
this case is to cure the infection, pneumonia. Corticosteroids and
bronchodilators are administered to asthmatic clients when they show
symptoms of wheezing. An ECG is used to evaluate atrial arrhythmias.
Quiz Stats

Answer Key
QUESTION 1: For both outpatients and inpatients scheduled for diagnostic procedures of
the cardiovascular system, the nurse performs a thorough initial assessment
to establish accurate baseline data. Which data is necessary to collect if the
client is experiencing chest pain?
Correct Response: description of the pain
Explanation: If the client is experiencing chest pain, a history of its location, frequency,
and duration is necessary. A description of the pain is needed, including
whether it radiates to a particular area, what precipitates its onset, and what
brings relief. The nurse weighs the client and measures vital signs. The nurse
may measure blood pressure in both arms and compare findings. The nurse
assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse
also checks peripheral pulses in the lower extremities.
QUESTION 2: For a client who has undergone peripheral arteriography, how should the
nurse assess the adequacy of peripheral circulation?
Correct Response: checking peripheral pulses
Explanation: Peripheral arteriography is used to diagnose occlusive arterial disease in

smaller arteries. The nurse observes the client for bleeding and cardiac
dysrhythmias and assesses the adequacy of peripheral circulation by
frequently checking the peripheral pulses. Hemodynamic monitoring is used
to assess the volume and pressure of blood in the heart and vascular system.
QUESTION 3: During auscultation of the lungs, what would a nurse note when assessing a
client with left-sided heart failure?
Correct Response: wheezes with wet lung sounds
Explanation: If the left side of the heart fails to pump efficiently, blood backs up into the
pulmonary veins and lung tissue. For abnormal and normal breath sounds, the
nurse auscultates the lungs. With left-sided congestive heart failure,
auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds
are accompanied by dyspnea and an effort to sit up to breathe. With left-

sided congestive heart failure, auscultation does not reveal a high pitched
sound.
QUESTION 4: During the auscultation of heart, what is revealed by an atrial gallop?
Correct Response: hypertensive heart disease
Explanation: Auscultation of the heart requires familiarization with normal and abnormal
heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial
gallop. An S4 sound often is associated with hypertensive heart disease. A
sound that follows S1 and S2 is called an S3 heart sound or a ventricular
gallop. An S3 heart sound is often an indication of heart failure in an adult. In
addition to heart sounds, auscultation may reveal other abnormal sounds,
such as murmurs and clicks, caused by turbulent blood flow through diseased
heart valves.
QUESTION 5: Which term describes the ability of the heart to initiate an electrical impulse?
Correct Response: automaticity
Explanation: Automaticity is the ability of specialized electrical cells of the cardiac

conduction system to initiate an electrical impulse. Contractility refers to the
ability of the specialized electrical cells of the cardiac conduction system to
contract in response to an electrical impulse. Conductivity refers to the
transmit an electrical impulse from one cell to another. Excitability refers to
the ability of the specialized electrical cells of the cardiac conduction system
to respond to an electrical impulse.
QUESTION 6: The nurse auscultates the apex beat at which anatomical location?
Correct Response: fifth intercostal space, midclavicular line
Explanation: The left ventricle is responsible for the apex beat or the point of maximum
impulse, which is normally palpable in the left midclavicular line of the chest
wall at the fifth intercostal space. The right ventricle lies anteriorly, just
beneath the sternum. Use of inches to identify the location of the apex beat
is inappropriate based upon variations in human anatomy. Auscultation below
and to the left of the xiphoid process will detect gastrointestinal sounds, but
not the apex beat of the heart.
QUESTION 7: Which term describes the amount of blood ejected per heartbeat?
Correct Response: stroke volume
Explanation: Stroke volume is determined by preload, afterload, and contractility of the

heart. Cardiac output is the amount of blood pumped by each ventricle during
a given period and is computed by multiplying the stroke volume of the heart
by the heart rate. Ejection fraction is the percentage of the end-diastolic
volume that is ejected with each stroke, measured at 42% to 50% in the
normal heart. Afterload is defined as the pressure that the ventricular
myocardium must overcome to eject blood during systole and is one of the
determinants of stroke volume.
QUESTION 8: Central venous pressure is measured in which heart chamber?
Correct Response: right atrium
Explanation: The pressure in the right atrium is used to assess right ventricular function
and venous blood return to the heart. The left atrium receives oxygenated
blood from the pulmonary circulation. The left ventricle receives oxygenated
blood from the left atrium. The right ventricle is not the central collecting
chamber of venous circulation.
QUESTION 9: When the balloon on the distal tip of a pulmonary artery catheter is inflated
and the pressure is measured, the measurement obtained is referred to as the
Correct Response: pulmonary artery wedge pressure.
Explanation: When the balloon is inflated, the tip of the catheter floats into smaller
branches of the pulmonary artery until it can no longer be passed. The
pressure is recorded, reflecting left-atrial pressure and left-ventricular end-
diastolic pressure. Central venous pressure is measured in the right atrium.
Pulmonary artery pressure is measured when the balloon tip is not inflated.
Cardiac output is determined through thermodilution, which involves
injection of fluid into the pulmonary artery catheter.
QUESTION 10: The nurse uses which term for the normal pacemaker of the heart?
Correct Response: Sinoatrial (SA) node
Explanation: The sinoatrial node is the primary pacemaker of the heart. The AV node
coordinates the incoming electrical impulses from the atria and, after a slight
delay, relays the impulse to the ventricles. The Purkinje fibers rapidly
conduct the impulses through the thick walls of the ventricles.
QUESTION 11: What is the term for the ability of the cardiac muscle to shorten in response
to an electrical impulse?
Correct Response: contractility
Explanation: Contractility is the ability of the cardiac muscle to shorten in response to an

electrical impulse. Depolarization is the electrical activation of a cell caused
by the influx of sodium into the cell while potassium exits the cell.
Repolarization is the return of the cell to the resting state, caused by reentry
of potassium into the cell while sodium exits the cell. Diastole is the period of
ventricular relaxation resulting in ventricular filling.
QUESTION 12: Age-related changes associated with the cardiac system include
Correct Response: endocardial fibrosis.
Explanation: Age-related changes associated with the cardiac system include: endocardial
fibrosis, increased size of the left atrium, a decreasing number of SA node
cells, and myocardial thickening.
QUESTION 13: Which symptom is an early warning sign of acute coronary syndrome (ACS)
and heart failure (HF)?
Correct Response: fatigue
Explanation: Fatigue is an early warning symptom of ACS, heart failure, and valvular
disease. Other signs and symptoms of cardiovascular disease are hypotension,
change in level of consciousness, and weight gain.
QUESTION 14: What does decreased pulse pressure reflect?
Correct Response: reduced stroke volume
Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection
velocity or obstruction to blood flow during systole. Increased pulse pressure
would indicate reduced distensibility of the arteries, along with bradycardia.
QUESTION 15: Which area of the heart that is located at the third intercostal space to the
left of the sternum?
Correct Response: Erb point
Explanation: Erb point is located at the third intercostal space to the left of the sternum.
The aortic area is located at the second intercostal space to the right of the
sternum. The pulmonic area is at the second intercostal space to the left of
the sternum. The epigastric area is located below the xiphoid process.
QUESTION 16: What is a harsh grating sound caused by abrasion of the pericardial surfaces
during the cardiac cycle?
Correct Response: friction rub
Explanation: During pericarditis, a harsh, grating sound that can be heard in both systole
and diastole is called a friction rub. A murmur is created by the turbulent
flow of blood. A cause of the turbulence may be a critically narrowed valve.
An opening snap is caused by high pressure in the left atrium with abrupt
displacement of a rigid mitral valve. An ejection click is caused by very high
pressure within the ventricle, displacing a rigid and calcified aortic valve.
QUESTION 17: For both outpatients and inpatients scheduled for diagnostic procedures of
the cardiovascular system, the nurse performs a thorough initial assessment
to establish accurate baseline data. Which data is necessary to collect if the
client is experiencing chest pain?
Correct Response: description of the pain
Explanation: If the client is experiencing chest pain, a history of its location, frequency,
and duration is necessary. A description of the pain is also needed, including
if it radiates to a particular area, what precipitates its onset, and what brings
relief. The nurse weighs the client and measures vital signs. The nurse may
measure blood pressure in both arms and compare findings. The nurse
assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse
also checks peripheral pulses in the lower extremities.
QUESTION 18: During the auscultation of a client’s heart sounds, the nurse notes an S4. The
nurse recognizes that an S4 is associated with which condition?
Correct Response: hypertensive heart disease
Explanation: Auscultation of the heart requires familiarization with normal and abnormal
heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial
gallop. An S4 sound often is associated with hypertensive heart disease. A
sound that follows S1 and S2 is called an S3 heart sound or a ventricular
gallop. An S3 heart sound is often an indication of heart failure in an adult. In
addition to heart sounds, auscultation may reveal other abnormal sounds,
such as murmurs and clicks, caused by turbulent blood flow through diseased
heart valves.
QUESTION 19: Which term describes the ability of the heart to initiate an electrical impulse?
Correct Response: automaticity
Explanation: Automaticity is the ability of specialized electrical cells of the cardiac

conduction system to initiate an electrical impulse. Contractility refers to the
contract in response to an electrical impulse. Conductivity refers to the
transmit an electrical impulse from one cell to another. Excitability refers to
the ability of the specialized electrical cells of the cardiac conduction system
to respond to an electrical impulse.
QUESTION 20: The nurse auscultates the PMI (point of maximal impulse) at which anatomic
location?
Correct Response: left midclavicular line, fifth intercostal space
Explanation: The left ventricle is responsible for the apical impulse or the point of
maximum impulse, which is normally palpable in the left midclavicular line of
the chest wall at the fifth intercostal space. The right ventricle lies
anteriorly, just beneath the sternum. Use of inches to identify the location of
the PMI is inappropriate based on variations in human anatomy. Auscultation
below and to the left of the xiphoid process will detect gastrointestinal
sounds, but not the PMI.
QUESTION 21: The balloon on the distal tip of a pulmonary artery catheter is inflated and
the pressure is measured. What is the term for the measurement obtained?
Correct Response: pulmonary artery wedge pressure
Explanation: When the balloon is inflated, the tip of the catheter floats into smaller
branches of the pulmonary artery until it can no longer be passed. The
pressure is recorded, reflecting left-atrial pressure and left-ventricular end-
diastolic pressure. Central venous pressure is measured in the right atrium.
Pulmonary artery pressure is measured when the balloon tip is not inflated.
Cardiac output is determined through thermodilution, which involves
injection of fluid into the pulmonary artery catheter.
QUESTION 22: The nurse uses which term for the normal pacemaker of the heart?
Correct Response: Sinoatrial (SA) node

Explanation: The sinoatrial node is the primary pacemaker of the heart. The AV node
coordinates the incoming electrical impulses from the atria and, after a slight
delay, relays the impulse to the ventricles. The Purkinje fibers rapidly
conduct the impulses through the thick walls of the ventricles.
QUESTION 23: Age-related changes associated with the cardiac system include which
conditions? Select all that apply.
Correct Response: endocardial fibrosis

increased size of the left atrium
Explanation: Age-related changes associated with the cardiac system include endocardial
fibrosis, increased size of the left atrium, decreased number of SA node cells,
and myocardial thickening.
QUESTION 24: What does decreased pulse pressure reflect?
Correct Response: reduced stroke volume
Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection
velocity or obstruction to blood flow during systole. Increased pulse pressure
would indicate reduced distensibility of the arteries, along with bradycardia.
QUESTION 25: Which area of the heart is located at the third intercostal (IC) space to the
left of the sternum?
Correct Response: erb point
Explanation: Erb point is located at the third IC space to the left of the sternum. The
aortic area is located at the second IC space to the right of the sternum. The
pulmonic area is at the second IC space to the left of the sternum. The
epigastric area is located below the xiphoid process.
QUESTION 26: What is a harsh grating sound caused by abrasion of the pericardial surfaces
during the cardiac cycle?
Correct Response: friction rub
Explanation: During pericarditis, a harsh, grating sound that can be heard in both systole
and diastole is called a friction rub. A murmur is created by the turbulent
flow of blood. A cause of the turbulence may be a critically narrowed valve.
An opening snap is caused by high pressure in the left atrium with abrupt
displacement of a rigid mitral valve. An ejection click is caused by very high

pressure within the ventricle, displacing a rigid and calcified aortic valve.
QUESTION 27: The nurse observes a client during an exercise stress test (bicycle). Which
finding indicates a positive test and the need for further diagnostic testing?
Correct Response: ST-segment changes on the ECG
Explanation: During the test, the following are monitored: two or more ECG leads for heart
rate, rhythm, and ischemic changes; blood pressure; skin temperature;
physical appearance; perceived exertion; and symptoms, including chest
pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated
when the target heart rate is achieved or if the client experiences signs of
myocardial ischemia. Further diagnostic testing, such as a cardiac
catheterization, may be warranted if the client develops chest pain, extreme
fatigue, a decrease in blood pressure or pulse rate, serious dysrhythmias or
ST-segment changes on the ECG during the stress test. The other findings
would not warrant stopping the test.
QUESTION 28: The nurse cares for a client in the ICU who is being monitored with a central
venous pressure (CVP) catheter. The nurse records the client’s CVP as 8 mm
Hg and recognizes that this finding indicates the client is experiencing which
condition?
Correct Response: hypervolemia
Explanation: The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an

elevated right ventricular preload. Many problems can cause an elevated CVP,
but the most common is hypervolemia (excessive fluid circulating in the body)
or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right-
ventricular preload, which is most often from hypovolemia.
QUESTION 29: The nurse cares for a client with diabetes who is scheduled for a cardiac
catheterization. Prior to the procedure, it is most important for the nurse to
ask which question?
Correct Response: “Are you allergic to shellfish?”
Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some
contrast agents contain iodine, and the client is assessed before the
procedure for previous reactions to contrast agents or allergies to iodine-
containing substances (e.g., seafood). If the client has a suspected or known
allergy to the substance, antihistamines or methylprednisolone may be
administered before the procedure. Although the other questions are
important to ask the client, it is most important to ascertain if the client has
an allergy to shellfish.
QUESTION 30: A nurse prepares to assess a client for postural blood pressure changes. Which
action indicates the nurse needs further education?
Correct Response: letting 30 seconds elapse after each position change before measuring BP and
HR
Explanation: The following steps are recommended when assessing clients for postural
hypotension: (1) Position the client supine for 10 minutes before taking the
initial BP and HR measurements; (2) reposition the client to a sitting position
with legs in the dependent position, and wait 2 minutes to reassess both BP
and HR measurements; (3) if the client is symptom free or has no significant
decreases in systolic or diastolic BP, assist the client into a standing position,
obtain measurements immediately and recheck in 2 minutes; (4) continue
measurements every 2 minutes for a total of 10 minutes to rule out postural
hypotension. Return the client to supine position if postural hypotension is
detected or if the client becomes symptomatic. Document HR and BP
measured in each position (e.g., supine, sitting, and standing) and any signs
or symptoms that accompanied the postural changes.
QUESTION 31: The nurse screens a client prior to a magnetic resonance angiogram (MRA) of
the heart. Which action should the nurse complete prior to the client
undergoing the procedure? Select all that apply.
Correct Response: Remove the client’s Transderm Nitro patch.

Offer the client a headset to listen to music during the procedure.
Remove the client’s jewelry.
Explanation: Transdermal patches that contain a heat-conducting aluminized layer (e.g.,

NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must
be removed before MRA to prevent burning of the skin. A client who is
claustrophobic may need to receive a mild sedative before undergoing an
MRA. During an MRA, the client is positioned supine on a table that is placed
into an enclosed imager or tube containing the magnetic field. Clients are
instructed to remove any jewelry, watches, or other metal items (e.g., ECG
leads). An intermittent clanking or thumping that can be annoying is
generated by the magnetic coils, so the client may be offered a headset to
listen to music.
QUESTION 32: The nurse prepares to apply ECG electrodes to a male client who requires
continuous cardiac monitoring. Which action should the nurse complete to
optimize skin adherence and conduction of the heart’s electrical current?
Correct Response: Clip the client’s chest hair prior to applying the electrodes.
Explanation: The nurse should complete the following actions when applying cardiac
electrodes: (1) Clip (do not shave) hair from around the electrode site, if
needed; (2) if the client is diaphoretic (sweaty), apply a small amount of
benzoin to the skin, avoiding the area under the center of the electrode; (3)
debride the skin surface of dead cells with soap and water and dry well (or as
recommended by the manufacturer); (4) change the electrodes every 24 to 48
hours (or as recommended by the manufacturer); (5) examine the skin for
irritation and apply the electrodes to different locations.
QUESTION 33: The nurse cares for a client in the emergency department who has a B-type
natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this
finding is most indicative of which condition?
Correct Response: heart failure
Explanation: A BNP level greater than 100 pg/mL is suggestive of heart failure. Because
this serum laboratory test can be quickly obtained, BNP levels are useful for
prompt diagnosis of heart failure in settings such as the emergency
department. Elevations in BNP can occur from a number of other conditions
such as pulmonary embolus, myocardial infarction (MI), and ventricular
hypertrophy. Therefore, the healthcare provider correlates BNP levels with
abnormal physical assessment findings and other diagnostic tests before
making a definitive diagnosis of heart failure.
QUESTION 34: The nurse cares for a client with clubbing of the fingers and toes. The nurse
should complete which action given these findings?
Correct Response: Obtain an oxygen saturation level.
Explanation: Clubbing of the fingers and toes indicates chronic hemoglobin desaturation
(decreased oxygen supply) and is associated with congenital heart disease.
The nurse should assess the client’s O2 saturation level and intervene as
directed. The other assessments are not indicated.
QUESTION 35: The nurse correctly identifies which data as an example of blood pressure and
heart rate measurements in a client with postural hypotension?
Correct Response: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm;
standing: BP 98/52 mm Hg, HR 94 bpm
Explanation: Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm

Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from
a lying or sitting position to a standing position. The following is an example
of BP and HR measurements in a client with postural hypotension: supine: BP

120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing:
BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a
person moves from a lying to a standing position include (1) a HR increase of
5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a
slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in
diastolic pressure.
QUESTION 36: The nurse reviews discharge instructions with a client who underwent a left
groin cardiac catheterization 8 hours ago. Which instructions should the nurse
include?
Correct Response: “Do not bend at the waist, strain, or lift heavy objects for the next 24 hours.”
Explanation: The nurse should instruct the client to follow these guidelines: For the next
24 hours, do not bend at the waist, strain, or lift heavy objects if the artery
of the groin was used; contact the primary provider if swelling, new bruising
or pain from the procedure puncture site, or a temperature of 101°F or more
occur. If bleeding occurs, lie down (groin approach) and apply firm pressure
to the puncture site for 10 minutes. Notify the primary provider as soon as
possible and follow instructions. If there is a large amount of bleeding, call
911. The client should not drive to the hospital.
QUESTION 37: The nurse cares for a client prescribed warfarin orally. The nurse reviews the
client’s prothrombin time (PT) level to evaluate the effectiveness of the
medication. Which laboratory values should the nurse also evaluate?
Correct Response: international normalized ratio (INR)
Explanation: The INR, reported with the PT, provides a standard method for reporting PT
levels and eliminates the variation of PT results from different laboratories.
The INR, rather than the PT alone, is used to monitor the effectiveness of
warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges
vary based on diagnosis. The other laboratory values are not used to evaluate
the effectiveness of warfarin.
QUESTION 38: The nurse cares for a client in the ICU diagnosed with coronary artery disease
(CAD). Which assessment data indicates the client is experiencing a decrease
in cardiac output?
Correct Response: disorientation, 20 mL of urine over the last 2 hours
Explanation: Assessment findings associated with reduced cardiac output include reduced
pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or
disorientation.
QUESTION 39: The nurse cares for a client with an intra-arterial blood pressure monitoring
device. The nurse recognizes the most preventable complication associated
with hemodynamic monitoring includes which condition?
Correct Response: catheter-related bloodstream infections
Explanation: Catheter-related bloodstream infections (CRBSIs) are the most common

preventable complication associated with hemodynamic monitoring systems.
Comprehensive guidelines for the prevention of these infections have been
published by Centers for Disease Control and Prevention (CDC). Complications
from use of hemodynamic monitoring systems are uncommon and can include
pneumothorax, infection, and air embolism. A pneumothorax may occur
during the insertion of catheters using a central venous approach (CVP and
pulmonary artery catheters). Air emboli can be introduced into the vascular
system if the stopcocks attached to the pressure transducers are mishandled
during blood drawing, administration of medications, or other procedures
that require opening the system to air.
Quiz Stats

Answer Key
QUESTION 1: Which of the following is a modifiable risk factor for coronary artery disease
(CAD)?
Correct Response: Hyperlipidemia
Explanation: Hyperlipidemia is a modifiable risk factor for CAD. Increasing age, male
gender, and family history are nonmodifiable risk factors for CAD.
QUESTION 2: A patient complains to the nurse about chest pain and palpitations during and
after his morning jogs. The patient's family history reveals a history of
coronary artery disease (CAD). What should the nurse recommend to minimize
cardiac risk?
Correct Response: Smoking cessation
Explanation: The first line of defense for patients with CAD is a change in lifestyle, such as
smoking cessation, weight loss, stress management, and exercise. A protein-
rich diet, liquid diet, and mild meals will not minimize cardiac risk.
QUESTION 3: The lab values of a patient diagnosed with coronary artery disease (CAD) have
just come back from the lab. His low-density lipoprotein (LDL) level is 112
mg/dL. This lab value is indicative of which of the following?
Correct Response: High LDL level
Explanation: If the LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered to be
high. The goal is to decrease the LDL level below 100 mg/dL.
QUESTION 4: Which of the following discharge instructions for self-care should the nurse
provide to a patient who has undergone a percutaneous transluminal coronary
angioplasty (PTCA) procedure?
Correct Response: Monitor the site for bleeding or hematoma.
Explanation: The nurse provides certain discharge instructions for self-care, such as
monitoring the site for bleeding or development of a hard mass indicative of
hematoma. A nurse does not advise the patient to clean the site with
disinfectants or refrain from sexual activity for one month.
QUESTION 5: A patient complains about chest pain and heavy breathing when exercising or
when stressed. Which of the following is a priority nursing intervention for
the patient diagnosed with coronary artery disease?
Correct Response: Assess chest pain and administer prescribed drugs and oxygen
Explanation: The nurse assesses the patient for chest pain and administers the prescribed
drugs that dilate the coronary arteries. The nurse administers oxygen to
improve the oxygen supply to the heart. Assessing the blood pressure or the
physical history does not clearly indicate that the patient has CAD. The nurse
does not administer aspirin without the physician's prescription.
QUESTION 6: Which of the following terms refers to chest pain brought on by physical or
emotional stress and relieved by rest or medication?
Correct Response: Angina pectoris
Explanation: Angina pectoris is a symptom of myocardial ischemia. Atherosclerosis is an

abnormal accumulation of lipid deposits and fibrous tissue within arterial
walls and lumens. Atheromas are fibrous caps composed of smooth muscle
cells that form over lipid deposits within arterial vessels. Ischemia is
insufficient tissue oxygenation and may occur in any part of the body.
QUESTION 7: Which of the following is a modifiable risk factor for coronary artery disease
(CAD)?
Correct Response: Diabetes mellitus
Explanation: While diabetes mellitus cannot be cured, blood sugars and symptomatology
can be managed through healthy heart living. Gender, race, and increasing
age are nonmodifiable risk factors.
QUESTION 8: Heparin therapy is usually considered therapeutic when the patient's

activated partial thromboplastin time (aPTT) is how many times normal?
Correct Response: 2 to 2.5

Explanation: The amount of heparin administered is based on aPTT results, which should
be obtained in follow-up to any alteration of dosage. The patient's aPTT value
would have to be greater than .5 to 1 times normal to be considered
therapeutic. An aPTT value that is 2.5 to 3 times normal would be too high to
be considered therapeutic. The patient's aPTT value would have to be greater
than .25 to .75 times normal to be considered therapeutic.
QUESTION 9: When the postcardiac surgery patient demonstrates restlessness, nausea,

weakness, and peaked T waves, the nurse reviews the patient's serum
electrolytes anticipating which abnormality?
Correct Response: Hyperkalemia
Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea,

weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would
likely be demonstrated by asystole. Hypomagnesemia would likely be
demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia
would likely be indicated by weakness, fatigue, and confusion without change
in T wave formation.
QUESTION 10: In order to be effective, percutaneous transluminal coronary angioplasty

(PTCA) must be performed within what time frame, beginning with arrival at
the emergency department after diagnosis of myocardial infarction?
Correct Response: 60 minutes
Explanation: The 60-minute interval is known as "door-to-balloon time" for performance of

PTCA on a diagnosed MI patient. The 30-minute interval is known as "door-to-
needle time" for administration of thrombolytics post MI. The time frame of 9
days refers to the time for onset of vasculitis after administration of
streptokinase for thrombolysis in an acute MI patient. The 6 to 12 month time
frame refers to the time period during which streptokinase will not be used
again in the same patient for acute MI.
QUESTION 11: A patient diagnosed with a myocardial infarction (MI) is being moved to the
rehabilitation unit for further therapies. Which of the following statements
reflect a goal of rehabilitation for the patient with an MI?
Correct Response: Improvement the quality of life
Explanation: Overall, cardiac rehabilitation is a complete program dedicated to extending

and improving quality of life. An immediate objective of rehabilitation of the
MI patient is to limit the effects and progression of atherosclerosis. An
immediate objective of rehabilitation of the MI patient is to return the
patient to work and a preillness lifestyle. An immediate objective of

rehabilitation of the MI patient is to prevent another cardiac event.
QUESTION 12: Which of the following methods to induce hemostasis after sheath removal
post percutaneous transluminal coronary angioplasty (PTCA) is the least
effective?
Correct Response: Application of a sandbag to the area
Explanation: Several nursing interventions frequently used as part of the standard of care,
such as applying a sandbag to the sheath insertion site, have not been shown
to be effective in reducing the incidence of bleeding. Application of a
vascular closure device has been demonstrated to be very effective. Direct
manual pressure to the sheath introduction site has been demonstrated to be
effective and was the first method used to induce hemostasis post PTCA.
Application of a pneumatic compression device post PTCA has been
demonstrated to be effective.
QUESTION 13: Which of the following medications is an antidote to heparin?
Correct Response: Protamine sulfate
Explanation: Protamine sulfate is known as the antagonist to heparin. Alteplase is a

thrombolytic agent. Clopidogrel (Plavix) is an antiplatelet medication that is
given to reduce the risk of thrombus formation post coronary stent
placement. The antiplatelet effect of aspirin does not reverse the effects of
heparin.
QUESTION 14: When the postcardiac surgical patient demonstrates vasodilation,

hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel
sounds), lethargy, and respiratory depression, the nurse suspects which of the
following electrolyte imbalances?
Correct Response: Hypermagnesemia
Explanation: Untreated hypomagnesemia may result in coma, apnea, and cardiac arrest.
Signs and symptoms of hypokalemia include signs of digitalis toxicity and
dysrhythmias (U wave, AV block, flat or inverted T waves). Signs of
hyperkalemia include: mental confusion, restlessness, nausea, weakness,
paresthesias of extremities, dysrhythmias (tall, peaked T waves; increased
amplitude, widening QRS complex; prolonged QT interval). Signs and
symptoms of hypomagnesemia include: paresthesias, carpopedal spasm,
muscle cramps, tetany, irritability, tremors, hyperexcitability, hyperreflexia,
cardiac dysrhythmias (prolonged PR and QT intervals, broad flat T waves),
disorientation, depression, and hypotension.
QUESTION 15: When the nurse notes that the post cardiac surgery patient demonstrates low
urine output (less than 25 mL per hour) with high specific gravity (greater
than 1.025), the nurse suspects which of the following conditions?
Correct Response: Inadequate fluid volume
Explanation: Urine output of less than 25 mL per hour may indicate a decrease in cardiac
output. A high specific gravity indicates increased concentration of solutes in
the urine which occurs with inadequate fluid volume. Indices of normal
glomerular filtration are output of 25 mLor greater per hour and specific
gravity between 1.010 and 1.025. Overhydration is manifested by high urine
output with low specific gravity. The anuric patient does not produce urine.
QUESTION 16: Which of the following techniques is used to surgically revascularize the
myocardium?
Correct Response: Minimally invasive direct coronary bypass
Explanation: There are several techniques used to surgically revascularize the

myocardium; one of them is minimally invasive direct coronary bypass.
Balloon bypass is not used to revascularize the myocardium. If the patient is
experiencing acute pain in the leg, peripheral bypass is performed. Gastric
bypass is a surgical procedure that alters the process of digestion.
QUESTION 17: Which of the following is the most important postoperative assessment
parameter for a patient recovering from cardiac surgery?
Correct Response: Inadequate tissue perfusion
Explanation: The nurse must assess the patient for signs and symptoms of inadequate
tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities,
or mottling of the skin. Although the nurse does assess blood sugar and
mental status, tissue perfusion is the higher priority. Assessing for activity
intolerance, while important later in the recovery period, is not essential in
the immediate postoperative period for patients undergoing cardiac surgery.
QUESTION 18: Which is a nonmodifiable risk factor for coronary artery disease (CAD)?
Correct Response: Gender
Explanation: Gender is a nonmodifable risk factor for coronary artery disease (CAD).
Hypertension, diabetes mellitus, and obesity are all modifiable risk factors.
QUESTION 19: Which of the following is also termed preinfarction angina?
Correct Response: Unstable angina
Explanation: Preinfarction angina is also known as unstable angina. Stable angina has
predictable and consistent pain that occurs on exertion and it relieved by
rest. Variant angina is exhibited by pain at rest with reversible ST-segment
elevation. In silent angina, there is evidence of ischemia, but the patient
reports no symptoms.
QUESTION 20: Which diagnostic is a marker for inflammation of vascular endothelium?
Correct Response: C-reactive protein (CRP)
Explanation: C-reactive protein (CRP) is a marker for inflammation of vascular

endothelium. LDL, HDL, and triglycerides are not marker of vascular
endothelium inflammation. They are elements of fat metabolism.
QUESTION 21: Which of the following medications is given to patients diagnosed with angina
and is allergic to aspirin?
Correct Response: Clopidogrel (Plavix)
Explanation: Plavix or Ticlid is given to patients who are allergic to aspirin or given in
addition to aspirin to patients at high risk for MI. Norvasc, Cardizem, and
Plendil are calcium channel blockers.
QUESTION 22: Heparin therapy is usually considered therapeutic when the aPTT is
Correct Response: 2 to 2.5 times the normal aPTT value.
Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 2 to 2.5
times the normal aPTT value. The other values are not within therapeutic
range.
QUESTION 23: The patient has had biomarkers drawn after complaining of chest pain. Which
diagnostic of myocardial infarction remains elevated for as long as 3 weeks?
Correct Response: Troponin
Explanation: Troponin remains elevated for a long period, often as long as 3 weeks, and it
therefore can be used to detect recent myocardial damage. Myoglobin returns
to normal in 12 hours. Total CK returns to normal in 3 days. CK-MB returns to
normal in 3 to 4 days.
QUESTION 24: Which of the following is the analgesic of choice for acute MI?
Correct Response: Morphine sulfate
Explanation: The analgesic of choice for acute MI is morphine sulfate administered in IV

boluses to reduce pain and anxiety. Aspirin is an antiplatelet medication.
Demerol and Motrin are not the analgesics of choice.
QUESTION 25: Which of the following in an inconsistent manifestation of metabolic

syndrome?
Correct Response: Hypotension
Explanation: Metabolic syndrome consists of insulin resistance, dyslipidemia, hypertension,

and chronic inflammation.
QUESTION 26: Which complication of cardiac surgery occurs when there is fluid and clot
accumulation in the pericardial sac, which compresses the heart, preventing
blood from filling the ventricles?
Correct Response: Cardiac tamponade
Explanation: Cardiac tamponade is fluid and clot accumulation in the pericardial sac,
which compresses the heart, preventing the blood from filling the ventricles.
Fluid overload is exhibited by high PAWP, CVP, and pulmonary artery diastolic
pressure as well as crackles in the lungs. Hypertension results from
postoperative vasoconstriction. Hypothermia is a low body temperature that
leads to vasoconstriction.
QUESTION 27: The nurse is caring for a client newly diagnosed with coronary artery disease
(CAD). While developing a teaching plan for the client to address modifiable
risk factors for CAD, the nurse will include which factor(s)? Select all that
apply.
Correct Response: Elevated blood pressure

Obesity
Explanation: Hypertension, obesity, hyperlipidemia, tobacco use, diabetes mellitus,

metabolic syndrome, and physical inactivity are modifiable risk factor for
CAD. Alcohol and drug use are not included in the list of modifiable risk
factors for CAD.
QUESTION 28: The nurse is reviewing the laboratory results for a patient diagnosed with
coronary artery disease (CAD). The patient’s low-density lipoprotein (LDL)
level is 115 mg/dL. The nurse interprets this value as which of the following?
Correct Response: High
Explanation: The normal LDL range is 100 mg/dL to 130 mg/dL. A level of 115 mg/dL is
considered to be high. The goal of treatment is to decrease the LDL level
below 100 mg/dL (less than 70 mg/dL for very high-risk patients).
QUESTION 29: When a patient who has been diagnosed with angina pectoris complains that
he is experiencing chest pain more frequently even at rest, the period of pain
is longer, and it takes less stress for the pain to occur, the nurse recognizes
that the patient is describing which type of angina?
Correct Response: Unstable
Explanation: Unstable angina is also called crescendo or preinfarction angina and indicates
the need for a change in treatment. Intractable or refractory angina produces
severe, incapacitating chest pain that does not respond to conventional
treatment. Variant angina is described as pain at rest with reversible ST-
segment elevation and is thought to be caused by coronary artery vasospasm.
Intractable or refractory angina produces severe, incapacitating chest pain
that does not respond to conventional treatment.
QUESTION 30: A nurse is caring for a patient post cardiac surgery. Upon assessment, the
patient appears restless and is complaining of nausea and weakness. The
patient’s ECG reveals peaked T waves. The nurse reviews the patient’s serum
electrolytes anticipating which of the following abnormalities?
Correct Response: Hyperkalemia
Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea,

weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would
likely be demonstrated by asystole. Hypomagnesemia would likely be
demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia
would likely be indicated by weakness, fatigue, and confusion without change
in T-wave formation.
QUESTION 31: In order to be effective, percutaneous transluminal coronary angioplasty

(PTCA) must be performed within what time frame, beginning with arrival at
the emergency department after diagnosis of myocardial infarction (MI)?
Correct Response: 60 minutes
Explanation: The 60-minute interval is known as “door-to-balloon time” for performance of

PTCA on a diagnosed MI patient. The 30-minute interval is known as “door-to-
needle time” for administration of thrombolytics post MI. The time frame of 9
days refers to the time for onset of vasculitis after administration of
streptokinase for thrombolysis in an acute MI patient. The 6- to 12-month
time frame refers to the time period during which streptokinase will not be
used again in the same patient for acute MI.
QUESTION 32: A patient diagnosed with a myocardial infarction (MI) has begun an active
rehabilitation program. The nurse recognizes an overall goal of rehabilitation
for a patient who has had an MI includes which of the following?
Correct Response: Improvement of the quality of life
Explanation: Overall, cardiac rehabilitation is a complete program dedicated to extending

and improving quality of life. An immediate objective of rehabilitation of the
MI patient is to limit the effects and progression of atherosclerosis. An
immediate objective of rehabilitation of the MI patient is to return the
patient to work and a preillness lifestyle. An immediate objective of
rehabilitation of the MI patient is to prevent another cardiac event.
QUESTION 33: Following a percutaneous coronary intervention (PCI), a patient is returned to

the nursing unit with large peripheral vascular access sheaths in place. The
nurse understands that which of the following methods to induce hemostasis
after sheath is contraindicated?
Correct Response: Application of a sandbag to the area
Explanation: Applying a sandbag to the sheath insertion site is ineffective in reducing the
incidence of bleeding and is not an acceptable standard of care. Application
of a vascular closure device (Angioseal, VasoSeal), direct manual pressure to
the sheath introduction site, and application of a mechanical compression
device (C-shaped clamp) are all appropriate methods used to induce
hemostasis following peripheral sheath removal.
QUESTION 34: The nurse is caring for a patient following a coronary artery bypass graft
(CABG). The nurse notes persistent oozing of bloody drainage from various
puncture sites. The nurse anticipates that the physician will order which of
the following medications to neutralize the unfractionated heparin the

patient received?
Correct Response: Protamine sulfate
Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it
neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel (Plavix) is
an antiplatelet medication that is given to reduce the risk of thrombus
formation post coronary stent placement. The antiplatelet effect of aspirin
does not reverse the effects of heparin.
QUESTION 35: The nurse is reevaluating a patient 2 hours following a percutaneous

transluminal coronary angioplasty (PTCA) procedure. Which of the following
assessment findings may indicate the patient is experiencing a complication
of the procedure?
Correct Response: Urine output of 40 mL
Explanation: Complications that may occur following a PTCA include myocardial ischemia,
bleeding and hematoma formation, retroperitoneal hematoma, arterial
occlusion, pseudoaneurysm formation, arteriovenous fistula formation, and
acute renal failure. The urine output of 40 mL over a 2-hour period may
indicate acute renal failure. The patient is expected to have a minimum urine
output of 30 mL per hour. Dried blood at the insertion site is a finding
warranting no acute intervention. A serum potassium level of 4.0 mEq/L is
within normal range. The heart rate of 100 bmp is within the normal range
and indicates no acute distress.
QUESTION 36: The nurse is caring for a patient presenting to the emergency department
(ED) complaining of chest pain. Which of the following electrocardiographic
(ECG) findings would be most concerning to the nurse?
Correct Response: ST elevations
Explanation: The first signs of an acute MI are usually seen in the T wave and ST segment.
The T wave becomes inverted; the ST segment elevates (usually flat). An
elevation in ST segment in two contiguous leads is a key diagnostic indicator
for MI (i.e. ST elevation myocardial infarction, STEMI). This patient requires
immediate invasive therapy or fibrinolytic medications. Although the other
ECG findings require intervention, elevated ST elevations require immediate
and definitive interventions.
QUESTION 37: A nurse is caring for a patient in the cardiovascular intensive care unit
(CVICU) following a coronary artery bypass graft (CABG). Which of the
following clinical findings requires immediate intervention by the nurse?
Correct Response: CVP reading: 1 mmHg
Explanation: The central venous pressure (CVP) reading of 1 is low (2–6 mmHg) and
indicates reduced right ventricular preload, commonly caused by
hypovolemia. Hypovolemia is the most common cause of decreased cardiac
output after cardiac surgery. Replacement fluids such as colloids, packed red
blood cells, or crystalloid solutions may be prescribed. The other findings
require follow-up by the nurse; however, addressing the CVP reading is the
nurse’s priority.
QUESTION 38: The nurse is caring for patient experiencing an acute MI (STEMI). The nurse
anticipates the physician will prescribe alteplase (Activase). Prior to
administering this medication, which of the following questions is most
important for the nurse to ask the patient?
Correct Response: “What time did your chest pain start today?”
Explanation: The patient may be a candidate for thrombolytic (fibrolytic) therapy. These
medications are administered if the patient’s chest pain lasts longer than 20
minutes, unrelieved by nitroglycerin, ST-segment elevation in the at least two
leads that face the same area of the heart, less than 6 hours from onset of
pain. The most appropriate question for the nurse to ask is in relationship to
when the chest pain began. The other questions would not aid in determining
if the patient is a candidate for thrombolytic therapy.
QUESTION 39: A patient presents to the emergency room complaining of chest pain. The
patient’s orders include the following elements. Which order should the nurse
complete first?
Correct Response: 12-lead ECG
Explanation: The nurse should complete the 12-lead ECG first. The priority is to determine
if the patient is suffering an acute MI and implement appropriate
interventions as quickly as possible. The other orders should be completed
after the ECG.
QUESTION 40: The nurse has completed a teaching session on the self-administration of
sublingual nitroglycerin. Which of the following patient statements indicates
that the patient teaching has been effective?
Correct Response: “I can take nitroglycerin prior to having sexual intercourse so I won’t develop
chest pain”.
Explanation: Nitroglycerin can be taken in anticipation of any activity that may produce
pain. Because nitroglycerin increases tolerance for exercise and stress when
taken prophylactically (i.e. before angina-producing activity, such as
exercise, stair-climbing, or sexual intercourse), it is best taken before pain
develops. The client is instructed to take three tablets 5 minutes apart and if
the chest pain is not relieved emergency medical services should be
contacted. Nitroglycerin is very unstable; it should be carried securely in its
original container (e.g., capped dark glass bottle); tablets should never be
removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin
includes: flushing, throbbing headache, hypotension, and tachycardia.
QUESTION 41: The nurse is caring for a patient who was admitted to the telemetry unit with
a diagnosis of rule/out acute MI. The patient’s chest pain began 3 hours ago.
Which of the following laboratory tests would be most helpful in confirming
the diagnosis of a current MI?
Correct Response: Creatinine kinase-myoglobin (CK-MB) level
Explanation: Elevated CK-MB assessment by mass assay is an indicator of acute MI; the
levels begin to increase within a few hours and peak within 24 hours of an MI.
If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier.
CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. There
are three isomers of troponin: C, I, and T. Troponin I and T are specific for
cardiac muscle, and these biomarkers are currently recognized as reliable and
critical markers of myocardial injury. An increase in myoglobin is not very
specific in indicating an acute cardiac event; however, negative results are an
excellent parameter for ruling out an acute MI.
QUESTION 42: A nurse is caring for a patient who experienced an MI. The patient is ordered
metoprolol (Lopressor). The nurse understands that the therapeutic effect of
this medication is which of the following?
Correct Response: Decreases resting heart rate
Explanation: The therapeutic effects of beta-adrenergic blocking agents such as

metoprolol are to reduce the myocardial oxygen consumption by blocking
beta-adrenergic sympathetic stimulation to the heart. The result is reduced
heart rate, slowed conduction of impulses through the conduction system,
decreased blood pressure, and reduced myocardial contractility to balance
the myocardial oxygen needs and amount of oxygen available. This helps to
control chest pain and delays the onset of ischemia during work or exercise.
This classification of medication also reduces the incidence of recurrent
angina, infarction, and cardiac mortality. Generally the dosage of medication
is titrated to achieve a resting heart rate of 50–60 bpm. Metoprolol is not
administered to decrease cholesterol levels, increase cardiac output, or
decrease platelet aggregation.
QUESTION 43: The nurse is caring for a patient diagnosed with unstable angina receiving IV
heparin. The patient is placed on bleeding precautions. Bleeding precautions
include which of the following measures?
Correct Response: Avoiding continuous BP monitoring
Explanation: The patient receiving heparin is placed on bleeding precautions, which can
include: applying pressure to the site of any needle punctures for a longer
time than usual, avoiding intramuscular injections, avoiding tissue injury and
bruising from trauma or constrictive devices (e.g. continuous use of an
automatic BP cuff). SQ injections are permitted; a soft toothbrush should be
used, and the patient may use nail clippers, but with caution.
QUESTION 44: A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which of the
following patient findings requires immediate intervention by the nurse?
Correct Response: Altered level of consciousness
Explanation: A patient receiving fibrinolytic therapy is at risk for complications associated

with bleeding. Altered level of consciousness may indicate hypoxia and
intracranial bleeding and the infusion should be discontinued immediately.
Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an
expected finding. A chest pain score of 2 is low, and indicates the patient’s
chest pain is subsiding, an expected outcome of this therapy.
QUESTION 45: A patient admitted to the coronary care unit (CCU) diagnosed with a STEMI is
anxious and fearful. Which of the following medications will the nurse
administer to relieve the patient’s anxiety and decrease cardiac workload?
Correct Response: IV morphine
Explanation: IV morphine is the analgesic of choice for treatment of an acute MI. It is given
to reduce pain and treat anxiety. It also reduces preload and afterload, which
decreases the workload of the heart. IV nitroglycerin is given to alleviate
chest pain. Administration of Tenormin and Norvasc are not indicated in this
situation.
QUESTION 46: The nurse recognizes that the treatment for a non-ST elevation myocardial
infarction (NSTEMI) differs from that of a patient with a STEMI, in that a
STEMI is more frequently treated with which of the following?
Correct Response: Percutaneous coronary intervention (PCI)
Explanation: The patient with a STEMI is often taken directly to the cardiac catheterization
laboratory for an immediate PCI. Superior outcomes have been reported with
the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are
used to treat NSTEMI.
QUESTION 47: The nurse is caring for a male patient who is being evaluated for lipid-
lowering medication. The patient’s laboratory results reveal the following:
Total cholesterol: 230 mg/dL, LDL: 120 mg/dL, and a triglyceride level of 310
mg/dL. Which of the following classes of medications would be most
appropriate for the patient based on his laboratory findings?
Correct Response: Nicotinic acids
Explanation: The most appropriate class of medications based on the patient’s laboratory
findings would be nicotinic acids. This class of medications is prescribed for
patients with: minimally elevated cholesterol and LDL levels or as an adjunct
to a statin when the lipid goal has not been has not been achieved and
triglyceride (TG) levels are elevated.
QUESTION 48: A middle-aged male presents to the ED complaining of severe chest

discomfort. Which of the following patient findings is most indicative of a
possible MI?
Correct Response: Chest discomfort not relieved by rest or nitroglycerin
Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated

with an acute MI. The other findings, although associated with ACS (acute
coronary syndrome) or MI, may also occur with angina and, alone, are not
indicative of an MI.
QUESTION 49: The nurse understands it is important to promote adequate tissue perfusion
following cardiac surgery. Which of the following measures should the nurse
complete to prevent deep venous thrombosis (DVT) and possible pulmonary
embolism (PE) development? Select all that apply.
Correct Response: Initiate passive exercises.

Avoid elevating the knees on the bed.
Apply antiembolism stockings.
Explanation: Preventative measures utilized to prevent venous stasis include: Application

of sequential pneumatic compression wraps or antiembolic stockings;
discouraging leg crossing; avoiding elevating the knees on the bed; omitting
pillows in the popliteal space; beginning passive exercises followed by active
exercises to promote circulation and prevent venous stasis.
QUESTION 50: A patient presents to the ED complaining of anxiety and chest pain after
shoveling heavy snow that morning. The patient says that he has not taken
nitroglycerin for months but did take three nitroglycerin tablets and although
the pain is less, “They did not work all that well. ” The patient shows the
nurse the nitroglycerin bottle and the prescription was filled 12 months ago.
The nurse anticipates which of the following physician orders?
Correct Response: Nitroglycerin SL
Explanation: Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and
time. Nitroglycerin should be renewed every 6 months to ensure full potency.
The client’s tablets were expired and the nurse should anticipate
administering nitroglycerin to assess if the chest pain subsides. The other
choices may be ordered at a later time, but the priority is to relieve the
patient’s chest pain.
QUESTION 51: A patient has had a 12-lead -ECG completed as part of an annual physical
examination. The nurse notes an abnormal Q wave on an otherwise
unremarkable ECG. The nurse recognizes this finding indicates which of the
following?
Correct Response: A past MI
Explanation: An abnormal Q wave may be present without ST-segment and T-wave changes,
which indicates an old, not acute, MI.
Quiz Stats

Answer Key
QUESTION 1: Which of the following instructions should a nurse provide a patient with a
history of rheumatic fever before the patient has any dental work done?
Correct Response: To take prophylactic antibiotics
Explanation: Patients with a history of rheumatic fever are susceptible to infective

endocarditis and should be asked to take prophylactic antibiotics before any
invasive procedure, including dental work. Steroids are prescribed to suppress
the inflammatory response and aspirin to control the formation of blood clots
around heart valves. Activities that require minimal activity are
recommended to reduce the work of the myocardium and counteract the
boredom of weeks of bed rest.
QUESTION 2: Which of the following nursing interventions should a nurse perform to reduce
cardiac workload in a patient diagnosed with myocarditis?
Correct Response: Maintain the patient on bed rest
Explanation: The nurse should maintain the patient on bed rest to reduce cardiac workload
and promote healing. The nurse should administer supplemental oxygen to
relieve tachycardia that may develop from hypoxemia. If the patient has a
fever, the nurse should administer a prescribed antipyretic along with
independent nursing measures like minimizing layers of bed linen, promoting
air circulation and evaporation of perspiration, and offering oral fluids. The
nurse should elevate the patient's head to promote maximal breathing
potential.
QUESTION 3: Which of the following nursing interventions should a nurse perform when a
patient with cardiomyopathy receives a diuretic?
Correct Response: Check for dependent edema regularly
Explanation: The nurse should monitor for dependent edema regularly if the patient with
cardiomyopathy receives a diuretic. Oxygen is administered either
continuously or when dyspnea or dysrhythmias develop. Bed rest is not
necessary. The nurse should ensure that the patient's activity level is reduced
and should sequence any activity that is slightly exertional between periods
of rest.
QUESTION 4: Which of the following describes a valve used in replacement surgery that is
made from the patient's own heart valve?
Correct Response: Autograft
Explanation: An example of autograft is found when the surgeon excises the pulmonic
valve and uses it for an aortic valve replacement. Allograft refers to
replacement using human tissue and is a synonym for homograft. Homograft
refers to replacement using human tissue and is a synonym for allograft.
Xenograft refers to replacement of tissue from animal tissue.
QUESTION 5: Which of the following procedures describes splitting or separating fused

cardiac valve leaflets?
Correct Response: Commissurotomy
Explanation: Commissurotomy is frequently used for mitral stenosis. Annuloplasty refers to

repair of a cardiac valve's outer ring. Chordoplasty refers to repair of the
chordae tendineae of atrioventricular valve leaflets. Valvuloplasty is a general
term that refers to repair of a stenosed or regurgitant cardiac valve by
commissurotomy, annuloplasty, leaflet repair, and/or chordoplasty.
QUESTION 6: Which of the following mitral valve conditions generally produces no

symptoms?
Correct Response: Prolapse
Explanation: Mitral valve prolapse is a deformity that usually produces no symptoms and
has been diagnosed more frequently in recent years, probably as a result of
improved diagnostic methods. Mitral valve stenosis usually causes progressive
fatigue. Mitral valve regurgitation, in its acute stage, usually presents as
severe heart failure. Mitral valve infection, when acute, will produce
symptoms typical of infective endocarditis.
QUESTION 7: In which type of cardiomyopathy does the heart muscle actually increase in
size and mass weight, especially along the septum?
Correct Response: Hypertrophic
Explanation: Because of the structural changes, hypertrophic cardiomyopathy had also

been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric
septal hypertrophy (ASH). Restrictive cardiomyopathy is characterized by
diastolic dysfunction caused by rigid ventricular walls that impair ventricular
stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy
(ARVC) occurs when the myocardium of the right ventricle is progressively
infiltrated and replaced by fibrous scar and adipose tissue.
QUESTION 8: Which of the following patient behaviors would indicate to the nurse that the
cardiac patient's level of anxiety has decreased?
Correct Response: Answers questions regarding status with no problem
Explanation: Generally, when anxiety begins to increase, the patient will be less likely to
want to discuss prognosis. Open discussion generally indicates some degree of
comfort with prognosis. Verbalization of fears and concerns indicates some
degree of comfort with prognosis. Participation in support groups indicates
some degree of comfort with prognosis.
QUESTION 9: The patient with which of the following characteristics is considered high risk
for the development of infective endocarditis?
Correct Response: Cyanotic congenital malformations
Explanation: The patient who has complex cyanotic congenital malformations is at high
risk for the development of infective endocarditis. The patient with mitral
valve prolapse with valvular regurgitation is at moderate risk for the
development of infective endocarditis. The patient with hypertrophic
cardiomyopathy is at moderate risk for the development of infective
endocarditis. The patient with acquired valvular dysfunction is at moderate
risk for the development of infective endocarditis.
QUESTION 10: Which of the following symptoms occurs in the patient diagnosed with mitral
regurgitation when pulmonary congestion occurs?
Explanation: If pulmonary congestion occurs, the patient with mitral regurgitation

develops shortness of breath. A loud, blowing murmur often is heard
throughout ventricular systole at the heart's apex. Hypertension may develop
when reduced cardiac output triggers the renin-angiotensin-aldosterone
cycle. Tachycardia is a compensatory mechanism when stroke volume
decreases.
QUESTION 11: An asymptomatic patient questions the nurse about mitral regurgitation and
inquires about continuing exercises. Which of the following is the most
appropriate nursing response?
Correct Response: Continue exercising until mild symptoms develop
Explanation: Exercise is not limited until mild symptoms develop. It is not important for an
asymptomatic patient to avoid exercise and to take ample rest after exercise.
QUESTION 12: Which of the following changes occur to the heart as a result of heart
transplant?
Correct Response: Heart beats faster than the natural heart
Explanation: The transplanted heart beats faster than the patient's natural heart,
averaging 100 to 110 beats/minute, because nerves that affect heart rate
have been severed. The new heart also takes longer to increase the heart
rate in response to exercise. Coronary artery disease (CAD) is a common
problem among heart transplant recipients.
QUESTION 13: Which type of graft is utilized when a heart valve replacement is made of
tissue from an animal heart valve?
Correct Response: Xenograft
Explanation: Xenograft refers to replacement of tissue from animal tissue. An autograft is

a heart valve replacement made from the patient's own heart valve. Allograft
refers to replacement using human tissue and is a synonym for homograft.
Homograft refers to replacement using human tissue and is a synonym for
allograft.
QUESTION 14: Which terms describes the backward flow of blood through a heart valve?
Correct Response: Regurgitation
Explanation: Regurgitation is a backward flow of blood through a heart valve. Stenosis

occurs when the valves don't open completely and the flow of blood through
the valve is reduced. Hypertrophy is an enlargement of an organ. A prolapse
is stretching of atrioventricular heart valve leaflet into the atrium during
systole.
QUESTION 15: Which valve lies between the right ventricle and the pulmonary artery?
Correct Response: Pulmonic
Explanation: The pulmonic valve is a semilunar valve located between the right ventricle
and the pulmonary artery. The tricuspid valve is an atrioventricular valve
located between the right atrium and right ventricle. The mitral valve is an
atrioventricular valve located between the left atrium and left ventricle.
Chordae tendineae anchor the valve leaflets to the papillary muscle and
ventricular wall.
QUESTION 16: What is the most common cause of mitral stenosis?
Correct Response: Rheumatic endocarditis
Explanation: Mitral stenosis is most often caused by rheumatic endocarditis, which

progressively thickens the mitral valve leaflets and chordate tendineae. In
adults, aortic stenosis is often a result of degenerative calcifications.
Congestive heart failure and myocardial infarction are not the most common
cause of mitral stenosis.
QUESTION 17: Which of the following types of cardiomyopathy are characterized by diastolic
dysfunction caused by rigid ventricular walls that impair diastolic filling and
ventricular stretch.
Correct Response: Restrictive cardiomyopathy (RCM)
Explanation: RCM is characterized by diastolic dysfunction caused by rigid ventricular walls

that impair diastolic filling and ventricular stretch. Hypertrophic
cardiomyopathy occurs when the heart muscle asymmetrically increases in
size and mass, especially along the septum. Dilated cardiomyopathy is

distinguished by significant dilation of the ventricles without simultaneous
hypertrophy. Arrhythmogenic right ventricular cardiomyopathy occurs when
the myocardium of the right ventricle is progressively infiltrated and replaced
by fibrous scar and adipose tissue.
QUESTION 18: Patient with myocarditis are sensitive to which of the following medications?
Correct Response: Digoxin
Explanation: The nurse must closely monitor these patients for digoxin toxicity, which is
evidenced by arrhythmia,, anorexia, nausea, vomiting, headache, and
malaise. If the cause of the myocarditis is hemolytic streptococci, penicillin
will be given. The use of corticosteroids remains controversial.
QUESTION 19: One of the most common causes of mitral valve regurgitation in people living
in developed countries is
Correct Response: ischemia of the left ventricle.
Explanation: The most common causes of mitral valve regurgitation in people living in
developed countries include degenerative changes in the mitral valve and
ischemia of the left ventricle. Other conditions leading to mitral regurgitation
include myxomatous changes, which enlarge and stretch the left atrium and
ventricle, causing leaflets and chordate tendineae to stretch or rupture and
ischemic heart disease. Rheumatic fever is the most common cause of mitral
valve regurgitation for people living in developing countries.
QUESTION 20: The nurse is auscultating the heart of a patient diagnosed with mitral valve
prolapse. Which of the following is often the first and only manifestation of
mitral valve prolapse?
Correct Response: An extra heart sound
Explanation: Often, the first and only sign of mitral valve prolapse is identified when a
physical examination of the heart reveals an extra heart sound referred to as
a mitral click. Fatigue, dizziness, and syncope are other symptoms of mitral
valve prolapsed.
QUESTION 21: Which of the following statements is not accurate regarding an autograft?
Correct Response: Anticoagulation is necessary.
Explanation: Anticoagulation is unnecessary because the valve is the patient's own tissue
and is not thrombogenic. Autografts are obtained by excising the patient's
own pulmonic valve and a portion of the pulmonary artery for use as the
aortic valve. The autograft is an alternative for children and women of
childbearing age. Aortic valve autografts have remained viable for more than
20 years.
QUESTION 22: Which of the following is a term used to describe the splitting or separating of
fused cardiac valve leaflets?
Explanation: Commissurotomy is the splitting or separating of fused cardiac valve leaflets.

Annuloplasty is a repair of a cardiac valve's outer ring. Chordoplasty is repair
of the stringy, tendinous fibers that connect the free edges of the
atrioventricular valve leaflets to the papillary muscle. Valvuloplasty is a
repair of a stenosed or regurgitant cardiac valve by commissurotomy,
annuloplasty, leaflet repair, or chordoplasty.
QUESTION 23: When teaching a patient with rheumatic carditis and a history of recurrent
rheumatic fever, which of the following statements made by the patient
indicates that teaching has been successful?
Correct Response: “I may have to take prophylactic antibiotics for up to 10 years.”
Explanation: Antibiotic prophylaxis for recurrent rheumatic fever with rheumatic carditis
may require 10 or more years of antibiotic coverage (e.g., penicillin G
intramuscularly (IM) every 4 weeks, penicillin V orally twice a day (BID),
sulfadiazine orally daily, or erythromycin orally BID. Patients with a history of
rheumatic fever are susceptible to infective endocarditis and should be asked
to take prophylactic antibiotics before any invasive procedure, including
dental work. Steroids are prescribed to suppress the inflammatory response
and aspirin to control the formation of blood clots around heart valves.
Activities that require minimal activity are recommended to reduce the work
of the myocardium and counteract the boredom of weeks of bed rest.
QUESTION 24: Which of the following nursing interventions should a nurse perform to reduce
cardiac workload in a patient diagnosed with myocarditis?
Correct Response: Maintain the patient on bed rest.
Explanation: The nurse should maintain the patient on bed rest to reduce cardiac workload
and promote healing. Bed rest also helps decrease myocardial damage and
the complications of myocarditis. The nurse should administer supplemental
oxygen to relieve tachycardia that may develop from hypoxemia. If the
patient has a fever, the nurse should administer a prescribed antipyretic along
with independent nursing measures such as minimizing layers of bed linen,
promoting air circulation and evaporation of perspiration, and offering oral
fluids. The nurse should elevate the patient’s head to promote maximal
breathing potential.
QUESTION 25: A patient with restrictive cardiomyopathy (RCM) is taking digoxin. Because of
the risk of increased sensitivity, the nurse should carefully assess the patient
for which of the following manifestations?
Correct Response: Anorexia and confusion
Explanation: Patients with RCM have increased sensitivity to digoxin, and the nurse must
anticipate that low doses will be prescribed and assess for digoxin toxicity.
The most common manifestations of digoxin toxicity are gastrointestinal
(anorexia, nausea, and vomiting), cardiac (rhythm disturbances and heart
block), and central nervous system (CNS) disturbances (confusion, headache,
weakness, dizziness, and blurred or yellow vision).
QUESTION 26: A nurse is teaching a patient about valve replacement surgery. Which
statement by the patient indicates an understanding of the benefit of an
autograft replacement valve?
Correct Response: “The valve is made from my own heart valve, and I will not need to take any
blood thinning drugs when I am discharged.”
Explanation: Autografts (i.e., autologous valves) are obtained by excising the patient’s own
pulmonic valve and a portion of the pulmonary artery for use as the aortic
valve. Anticoagulation is unnecessary because the valve is the patient’s own
tissue and is not thrombogenic. The autograft is an alternative for children (it
may grow as the child grows), women of childbearing age, young adults,
patients with a history of peptic ulcer disease, and people who cannot
tolerate anticoagulation. Aortic valve autografts have remained viable for
more than 20 years.
QUESTION 27: A nurse reviewing a patient’s echocardiogram report reads the following
statements: “The heart muscle is asymmetrically thickened and has an
increase in overall size and mass, especially along the septum. The
ventricular walls are thickened reducing the size of the ventricular cavities.
Several areas of the myocardium have evidence of scaring.” The nurse knows
these manifestations are indicative of which type of cardiomyopathy?
Correct Response: Hypertrophic
Explanation: In hypertrophic cardiomyopathy (HCM), the heart muscle asymmetrically

increases in size and mass, especially along the septum. It often affects
nonadjacent areas of the ventricle. The increased thickness of the heart
muscle reduces the size of the ventricular cavities and causes the ventricles
to take a longer time to relax after systole. The coronary arteriole walls are
also thickened, which decreases the internal diameter of the arterioles. The
narrow arterioles restrict the blood supply to the myocardium, causing
numerous small areas of ischemia and necrosis. The necrotic areas of the
myocardium ultimately fibrose and scar, further impeding ventricular
contraction. Because of the structural changes, HCM had also been called
idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal
hypertrophy (ASH). RCM is characterized by diastolic dysfunction caused by
rigid ventricular walls that impair ventricular stretch and diastolic filling.
Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the
myocardium of the right ventricle is progressively infiltrated and replaced by
fibrous scar and adipose tissue.
QUESTION 28: A nurse caring for a patient with cardiomyopathy determines a diagnosis of
anxiety related to a fear of death. Which of the following patient behaviors
would indicate to the nurse that the patient’s level of anxiety has decreased?
Correct Response: The patient is able to discuss the prognosis freely.
Explanation: As anxiety decreases, patients will be able to discuss prognosis freely,

verbalize fears and concerns, and participate in support groups.
QUESTION 29: A patient with a myocardial infarction develops acute mitral valve
regurgitation. The nurse knows to assess for which of the following
manifestations that would indicate that the patient is developing pulmonary
congestion?
Explanation: Chronic mitral regurgitation is often asymptomatic, but acute mitral

regurgitation (e.g., resulting from a myocardial infarction) usually manifests
as severe congestive heart failure. Dyspnea, fatigue and weakness are the
most common symptoms. Palpitations, shortness of breath on exertion, and
cough from pulmonary congestion also occur. A loud, blowing murmur often is
heard throughout ventricular systole at the heart’s apex. Hypertension may
develop when reduced cardiac output triggers the renin-angiotensin-
aldosterone cycle. Tachycardia is a compensatory mechanism when stroke
volume decreases.
QUESTION 30: An asymptomatic patient questions the nurse about the diagnosis of mitral
regurgitation and inquires about continuing an exercise routine. Which of the
following is the most appropriate nursing response?
Correct Response: Continue the exercise routine unless symptoms such as shortness of breath or
fatigue develop.
Explanation: Exercise is not limited until mild symptoms develop. Once symptoms of heart
failure develop, the patient needs to restrict his or her activity level to
minimize symptoms. It is not important for an asymptomatic patient to avoid
exercise and to take ample rest after exercise.
QUESTION 31: A nurse is teaching a patient who is awaiting a heart transplant. Which of the
following statements indicate the patient understands what is required to
help minimize rejection?
Correct Response: “I will need to take three different types of medications for the rest of my
life to help prevent rejection.”
Explanation: Patients who have had heart transplants are constantly balancing the risk of
rejection with the risk of infection. They must adhere to a complex regimen
of diet, medications, activity, follow-up laboratory studies, biopsies of the
transplanted heart (to diagnose rejection), and clinic visits. There are three
classes of medications that are prescribed for a transplant patient to help
minimize rejection: corticosteroids (e.g., prednisone), calcineurin inhibitors
(tacrolimus, cyclosporin), and antiproliferative agents (mycophenolate
mofetil [CellCept], azathioprine [Imuran], or sirolimus [Rapamune]).
QUESTION 32: A nurse is conducting a heath history on a patient with a primary diagnosis of
mitral stenosis. Which of the following disorders reported by the patient is
the most common cause of mitral stenosis?
Correct Response: Rheumatic endocarditis
Explanation: Mitral stenosis is most often caused by rheumatic endocarditis, which

progressively thickens the mitral valve leaflets and chordate tendineae.
Leaflets often fuse together. Eventually, the mitral valve orifice narrows and
progressively obstructs blood flow into the ventricle.
QUESTION 33: The nurse is auscultating the heart of a patient diagnosed with mitral valve
prolapse. Which of the following is often the first and only manifestation of
mitral valve prolapse?
Correct Response: Extra heart sound
Explanation: Often, the first and only sign of mitral valve prolapse is identified when a
physical examination of the heart reveals an extra heart sound referred to as
a mitral click. Fatigue, dizziness, and syncope are other symptoms of mitral
valve prolapsed.
QUESTION 34: A nurse is teaching a patient about an upcoming surgery to separate fused
cardiac leaflets. Which of the following is the correct term used to describe
this surgery?
Explanation: Commissurotomy is the splitting or separating of fused cardiac valve leaflets.

Annuloplasty is a repair of a cardiac valve’s outer ring. Chordoplasty is repair
of the stringy, tendinous fibers that connect the free edges of the
atrioventricular valve leaflets to the papillary muscle. Valvuloplasty is a
repair of a stenosed or regurgitant cardiac valve by commissurotomy,
annuloplasty, leaflet repair, or chordoplasty.
QUESTION 35: A patient comes to the clinic with complaints of fever, chills, and sore throat
and is diagnosed with streptococcal pharyngitis. A nurse knows that early
diagnosis and effective treatment is essential to avoid which of the following
preventable diseases?
Correct Response: Rheumatic fever
Explanation: Rheumatic fever is a preventable disease. Diagnosing and effectively treating

streptococcal pharyngitis can prevent rheumatic fever and, therefore,
rheumatic heart disease.
QUESTION 36: A patient comes into the emergency room complaining about chest pain that
gets worse when taking deep breaths and lying down. After ruling out a
myocardial infarction, a nurse would assess for which of the following
diagnoses?
Correct Response: Pericarditis
Explanation: The primary symptom of pericarditis is pain, which is assessed by evaluating

the patient in various positions. The nurse tries to identify whether pain is
influenced by respiratory movements while holding an inhaled breath or
holding an exhaled breath; by flexion, extension, or rotation of the spine,
including the neck; by movements of shoulders and arms; by coughing; or by
swallowing. Recognizing events that precipitate or intensify pain may help
establish a diagnosis and differentiate pain of pericarditis from pain of
myocardial infarction.
QUESTION 37: A patient complaining of heart palpitations is diagnosed with atrial fibrillation
caused by mitral valve prolapse. In order to relieve the symptoms, the nurse
should teach the patient which of the following dietary interventions?
Correct Response: Eliminate caffeine and alcohol
Explanation: To minimize symptoms of mitral valve prolapse, the nurse should instruct the
patient to avoid caffeine and alcohol. The nurse encourages the patient to
read product labels, particularly on over-the-counter products such as cough
medicine, because these products may contain alcohol, caffeine, ephedrine
and adrenaline, which may produce arrhythmias and other symptoms. The
nurse also explores possible diet, activity, sleep, and other lifestyle factors
that may correlate with symptoms.
QUESTION 38: Which of the following teaching interventions should the nurse include in the
plan of care for a patient with valvular heart disease who is experiencing
pulmonary congestion?
Correct Response: Teaching patients to rest and sleep in a chair or sit in bed with head elevated
Explanation: Patients who experience symptoms of pulmonary congestion are advised to

rest and sleep sitting in a chair or bed with the head elevated. In addition,
the nurse educates the patient to take a daily weight and report gains of 3
pounds in 1 day or 5 pounds in 1 week to the primary provider. The nurse may
assist the patient with planning activity and rest periods to achieve an
acceptable lifestyle.
QUESTION 39: A patient is admitted with aortic regurgitation. Which of the following
medication classifications are contraindicated since they can cause
bradycardia and decrease ventricular contractility?
Correct Response: Calcium channel blockers
Explanation: The calcium channel blockers diltiazem (Cardizem) and verapamil (Calan,
Isoptin) are contraindicated for patients with aortic regurgitation as they
decrease ventricular contractility and may cause bradycardia.
QUESTION 40: A nurse is caring for a patient who had an aortic balloon valvuloplasty. The
nurse would inspect the surgical insertion site closely for which of the
following complications?
Correct Response: Bleeding and infection
Explanation: Possible complications of an aortic balloon valvuloplasty include aortic

regurgitation, emboli, ventricular perforation, rupture of the aortic valve
annulus, ventricular dysrhythmia, mitral valve damage, infection, and
bleeding from the catheter insertion sites.
QUESTION 41: The nurse obtains a health history from a patient with a prosthetic heart
valve and new symptoms of infective endocarditis. Which question by the
nurse is most appropriate to ask?
Correct Response: Have you been to the dentist recently?
Explanation: Invasive procedures, particularly those involving mucosal surfaces (e.g., those
involving manipulation of gingival tissue or periapical regions of teeth), can
cause a bacteremia, which rarely lasts more than 15 minutes. However, if a
patient has any anatomic cardiac defects or implanted cardiac devices (e.g.,
prosthetic heart valve, pacemaker, implantable cardioverter defibrillator
[ICD]), bacteremia can cause bacterial endocarditis.
QUESTION 42: The nurse is assessing a patient admitted with infective endocarditis. Which
of the following manifestations would the nurse expect to find?
Correct Response: Small painful lesions on the pads of the fingers and toes
Explanation: Primary presenting symptoms of infective endocarditis are fever and a heart
murmur. In addition small, painful nodules (Osler nodes) may be present in
pads of fingers or toes.
QUESTION 43: Which action will a public health nurse include when planning ways to
decrease the incidence of rheumatic fever in the community?
Correct Response: Teach individuals of the community to seek medical treatment for
streptococcal pharyngitis.
Explanation: Prevention of acute rheumatic fever is dependent upon effective antibiotic

treatment of streptococcal pharyngitis. Family history is not a risk factor for
rheumatic fever. There is no immunization that is effective in decreasing the
incidence of rheumatic fever. Education about monitoring temperature will
not decrease the incidence of rheumatic fever.
QUESTION 44: A patient with infective endocarditis (IE) and a fever is admitted to the
intensive care unit (ICU). Which of these physician orders should the nurse
implement first?
Correct Response: Order blood cultures drawn from two sites.
Explanation: Blood cultures (with each set including one aerobic and one anaerobic
culture) drawn from different venipuncture sites over a 24-hour period (each
set at least 12 hours apart), or every 30 minutes if the patient’s condition is
unstable, should be obtained before administration of any antimicrobial
agents. It is essential to obtain blood cultures before initiating antibiotic
therapy to obtain accurate sensitivity results.
QUESTION 45: A patient is admitted to the hospital with possible acute pericarditis and
pericardial effusion. The nurse knows to prepare the patient for which
diagnostic test used to confirm the patient’s diagnosis?
Correct Response: Echocardiogram
Explanation: Echocardiograms are useful in detecting the presence of the pericardial

effusions associated with pericarditis. An echocardiogram may detect
inflammation, pericardial effusion, tamponade, and heart failure. It may help
confirm the diagnosis.
QUESTION 46: A patient who has had a recent myocardial infarction develops pericarditis
and complains of level 6 (on a scale of 0–10) chest pain with deep breathing.
Which of these ordered pro re nata (PRN) medications will be the most
appropriate for the nurse to administer?
Correct Response: Ibuprofen (Motrin) 800 mg po every 8 hours
Explanation: Pain associated with pericarditis is caused by inflammation, thus nonsteroidal

anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid
analgesics are usually not used for the pain associated with pericarditis.
QUESTION 47: A patient with a recent myocardial infarction was admitted to the hospital
with a new diagnosis of mitral valve regurgitation. Which of the following
assessment data obtained by the nurse should be immediately communicated
to the health care provider?
Correct Response: The patient has crackles audible throughout the lungs.
Explanation: Acute mitral regurgitation, resulting from a myocardial infarction, usually

manifests as severe congestive heart failure. Dyspnea, fatigue and weakness
are the most common symptoms. Palpitations, shortness of breath on exertion
and cough from pulmonary congestion also occur. Crackles that are audible
throughout the lungs indicate that the patient is experiencing severe left
ventricular failure with pulmonary congestion and need immediate
interventions, such as diuretics.
Quiz Stats

Answer Key
QUESTION 1: Which particular area(s) should be examined to assess peripheral edema?
Correct Response: Feet, ankles
Explanation: When right-sided heart failure occurs, blood accumulates in the vessels and
backs up in peripheral veins, and the extra fluid enters the tissues. Particular
areas for examination are the dependent parts of the body, such as the feet
and ankles. Other prominent areas prone to edema are the fingers, hands,
and over the sacrum. Cyanosis can be detected by noting color changes in the
lips and earlobes.
QUESTION 2: Which nursing intervention should a nurse perform when a client with valvular
disorder of the heart has a heart rate less than 60 beats per minute before
administering a beta-blocker?
Correct Response: Withhold the drug and inform the primary health care provider
Explanation: Before administering beta-blockers, the nurse should monitor the client's
apical pulse. If the heart rate is less than 60 beats per minute, the nurse
should withhold the drug and inform the primary health care provider.
QUESTION 3: Which assessment parameter is important for the client diagnosed with
congestive heart failure?
Correct Response: Distended veins
Explanation: During a head-to-toe assessment of a client with congestive heart failure, the
nurse checks for dyspnea, auscultates apical heart rate, counts radial heart
rate, measures BP, checks for distended neck veins, and documents any signs
of peripheral edema, lethargy, or confusion. The nurse need not examine
joints for crepitus, eyes for excess tearing, or signs of photosensitivity
because these are not symptoms of congestive heart failure.
QUESTION 4: A client is prescribed digitalis medication. Which condition should the nurse

closely monitor when caring for the client?
Correct Response: Electrolyte and water loss
Explanation: The nurse should closely monitor a client being administered diuretics for
electrolyte and water loss. Digitalis medications (not diuretics) are potent
and may cause various toxic effects. The nurse should monitor the client for
signs of digitalis toxicity, not just during the initial period of therapy, but
throughout care management. However, the effects do not include vasculitis,
flexion contractures, or enlargement of joints.
QUESTION 5: A client has been diagnosed with congestive heart failure. Which is a cause of
crackles heard in the bases of the lungs?
Correct Response: Pulmonary congestion
Explanation: Crackles heard in the bases of the lungs are a sign of pulmonary congestion.
Heart palpitations are caused by tachydysrhythmias. Crackles heard in the
bases of the lungs are not signs of pulmonary hypertension and mitral valve
stenosis.
QUESTION 6: Older adults with a history of which condition are at risk for

thrombophlebitis?
Correct Response: Coronary artery disease
Explanation: Older adults with heart and blood vessel diseases are susceptible to
thrombophlebitis because of impaired mobility, reduced activity, and
compromised circulation. Thrombophlebitis is an inflammatory process that
causes a blood clot to form and block one or more veins.
QUESTION 7: Which medication is categorized as a loop diuretic?
Correct Response: Furosemide
Explanation: Furosemide is commonly used to treat cardiac failure. Loop diuretics inhibit
sodium and chloride reabsorption mainly in the ascending loop of Henle.
Chlorothiazide and chlorthalidone are categorized as thiazide diuretics.
Spironolactone is categorized as a potassium-sparing diuretic.
QUESTION 8: When a client has increased difficulty breathing when lying flat, the nurse
records that the client is demonstrating
Correct Response: orthopnea.
Explanation: Clients with orthopnea prefer not to lie flat and will need to maintain their
beds in a semi- to high Fowler position. Dyspnea upon exertion refers to
difficulty breathing with activity. Hyperpnea refers to increased rate and
depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that
occurs only at night.
QUESTION 9: The client with cardiac failure is taught to report which symptom to the
physician or clinic immediately?
Correct Response: Persistent cough
Explanation: Persistent cough may indicate an onset of left-sided heart failure. Loss of
appetite, weight gain, interrupted sleep, unusual shortness of breath, and
increased swelling should also be reported immediately.
QUESTION 10: Which term describes the degree of stretch of the ventricular cardiac muscle
fibers at the end of diastole?
Correct Response: Preload
Explanation: Preload is the the degree of stretch of the ventricular cardiac muscle fibers at
the end of diastole. Afterload is the amount of resistance to ejection of blood
from a ventricle. The ejection fraction is the percentage of blood volume in
the ventricles at the end of diastole that is ejected during systole. Stroke
volume is the amount of blood pumped out of the ventricle with each
contraction.
QUESTION 11: Which is the hallmark of heart failure?
Correct Response: Low ejection fraction (EF)
Explanation: Although a low EF is a hallmark of heart failure (HF), the severity of HF is

frequently classified according to the client's symptoms. Pulmonary
congestion, limitation of ADLs, and basilar crackles are all symptoms of HF.
QUESTION 12: Which New York Heart Association classification of heart failure has a poor
prognosis and includes symptoms of cardiac insufficiency at rest?
Correct Response: IV
Explanation: Symptoms of cardiac insufficiency at rest are classified as IV, according to the
New York Heart Association Classification of Heart Failure. In class I, ordinary
activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In
class II, ADLs are slightly limited. In class III, ADLs are markedly limited.
QUESTION 13: Which is a cerebrovascular manifestation of heart failure?
Correct Response: Dizziness
Explanation: Cerebrovascular manifestations of heart failure include dizziness,

lightheadedness, confusion, restlessness, and anxiety. Tachycardia is a
cardiovascular manifestation. Ascites is a gastrointestinal manifestation.
Nocturia is a renal manifestation.
QUESTION 14: Which is a characteristic of right-sided heart failure?
Correct Response: Jugular vein distention
Explanation: Jugular vein distention is a characteristic of right-sided heart failure.

Dyspnea, pulmonary crackles, and cough are manifestations of left-sided
heart failure.
QUESTION 15: Which diagnostic study is usually performed to confirm the diagnosis of heart
failure?
Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart

failure. ECG, serum electrolytes, and a BUN are usually completed during the
initial workup.
QUESTION 16: Which is a key diagnostic indicator of heart failure?
Correct Response: Brain natriuretic peptide (BNP)
Explanation: BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high
cardiac filling pressure and can aid in the diagnosis of heart failure. BUN,
creatinine, and a CBC are included in the initial workup.
QUESTION 17: Which is a potassium-sparing diuretic used in the treatment of heart failure?
Correct Response: Spironolactone
Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide

diuretic. Bumetanide and ethacrynic acid are loop diuretics.
QUESTION 18: Which medication reverses digitalis toxicity?
Correct Response: Digoxin immune FAB
Explanation: Digoxin immune FAB binds with digoxin and makes it unavailable for use. The
dosage is based on the digoxin concentration and the client's weight.
Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of
digoxin.
QUESTION 19: Which is a manifestation of right-sided heart failure?
Correct Response: Systemic venous congestion
Explanation: Right-sided heart failure causes systemic venous congestion and a reduction
in forward flow. Left-sided heart failure causes an accumulation of blood in
the lungs and a reduction in forward flow or cardiac output that results in
inadequate arterial blood flow to the tissues.
QUESTION 20: Which is a classic sign of cardiogenic shock?
Correct Response: Tissue hypoperfusion
Explanation: Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness,

confusion, agitation). Low blood pressure is a classic sign of cardiogenic
shock. Hypoactive bowel sounds are classic signs of cardiogenic shock.
Decreased urinary output is a classic sign of cardiogenic shock.
QUESTION 21: Which nursing intervention should the nurse perform when a client with
valvular disorder of the heart has a heart rate less than 60 beats/min before
administering beta-blockers?
Correct Response: Withhold the drug and inform the primary health care provider.
Explanation: Before administering a beta-blocker, the nurse should monitor the client’s
apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold
the drug and inform the primary health care provider.
QUESTION 22: A nurse is assessing a client with congestive heart failure for jugular vein
distension (JVD). Which observation is important to report to the physician?
Correct Response: JVD is noted 4 cm above the sternal angle.
Explanation: JVD is assessed with the client sitting at a 45° angle. Jugular vein distention
greater than 4 cm above the sternal angle is considered abnormal and is
indicative of right ventricular failure.
QUESTION 23: When the client has increased difficulty breathing when lying flat, the nurse
records that the client is demonstrating
Correct Response: orthopnea.
Explanation: Clients with orthopnea prefer not to lie flat and will need to maintain their
beds in a semi- to high Fowler position. Dyspnea upon exertion refers to
difficulty breathing with activity. Hyperpnea refers to increased rate and
depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that
occurs only at night.
QUESTION 24: A client with congestive heart failure is admitted to the hospital after
reporting shortness of breath. How should the nurse position the client in
order to decrease preload?
Correct Response: Head of the bed elevated 45 degrees and lower arms supported by pillows
Explanation: Preload refers to the degree of stretch of the ventricular cardiac muscle
fibers at the end of diastole. The client is positioned or taught how to assume
a position that facilitates breathing. The number of pillows may be increased,
the head of the bed may be elevated, or the client may sit in a recliner. In
these positions, the venous return to the heart (preload) is reduced,
pulmonary congestion is alleviated, and pressure on the diaphragm is
minimized. The lower arms are supported with pillows to eliminate the
fatigue caused by the pull of the client’s weight on the shoulder muscles.
QUESTION 25: Which feature is the hallmark of systolic heart failure?
Correct Response: Low ejection fraction (EF)
Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is

frequently classified according to the client’s symptoms.
QUESTION 26: The nurse assessing a client with an exacerbation of heart failure identifies
which symptom as a cerebrovascular manifestation of heart failure (HF)?
Correct Response: Dizziness
Explanation: Cerebrovascular manifestations of heart failure stemming from decreased

brain perfusion include dizziness, lightheadedness, confusion, restlessness,
and anxiety due to decreased oxygenation and blood flow.
QUESTION 27: Which describes difficulty breathing when a client is lying flat?
Correct Response: Orthopnea
Explanation: Orthopnea occurs when the client is having difficulty breathing when lying
flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal
dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow
breathing rate.
QUESTION 28: The nurse identifies which symptom as a characteristic of right-sided heart
failure?
Correct Response: Jugular vein distention (JVD)
Explanation: JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary

crackles, and cough are manifestations of left-sided heart failure.
QUESTION 29: Which diagnostic study is usually performed to confirm the diagnosis of heart
failure?
Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart

failure. ECG, serum electrolytes, and a BUN are usually completed during the
initial workup.
QUESTION 30: The nurse recognizes that which laboratory test is a key diagnostic indicator
of heart failure?

Correct Response: Brain natriuretic peptide (BNP)
Explanation: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a
sign of high cardiac filling pressure and can aid in the diagnosis of heart
failure. A BUN, creatinine, and CBC are included in the initial workup.
QUESTION 31: Which is a potassium-sparing diuretic used in the treatment of heart failure
(HF)?
Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide

diuretic is Diuril. Bumetanide and ethacrynic acid are loop diuretics.
QUESTION 32: The nurse identifies which symptom as a manifestation of right-sided heart
failure (HF)?
Correct Response: Congestion in the peripheral tissues
Explanation: Right-sided HF, failure of the right ventricle, results in congestion in the
peripheral tissues and the viscera and causes systemic venous congestion and
a reduction in forward flow. Left-sided HF refers to failure of the left
ventricle; it results in pulmonary congestion and causes an accumulation of
blood in the lungs and a reduction in forward flow or cardiac output that
results in inadequate arterial blood flow to the tissues.
QUESTION 33: The nurse recognizes which symptom as a classic sign of cardiogenic shock?
Correct Response: Restlessness and confusion
Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate
tissue perfusion and initiation of the shock syndrome. Inadequate tissue
perfusion is manifested as cerebral hypoxia (restlessness, confusion,
agitation).
QUESTION 34: A nurse is teaching clients newly diagnosed with coronary heart disease (CHD)
about the disease process and risk factors for heart failure. Which
problem can cause left-sided heart failure (HF)?
Correct Response: Myocardial ischemia
Explanation: Myocardial dysfunction and HF can be caused by a number of conditions,

including coronary artery disease, hypertension, cardiomyopathy, valvular
disorders, and renal dysfunction with volume overload. Atherosclerosis of the

coronary arteries is a primary cause of HF, and coronary artery disease is
found in the majority of clients with HF. Ischemia causes myocardial
dysfunction because it deprives heart cells of oxygen and causes cellular
damage. MI causes focal heart muscle necrosis, myocardial cell death, and a
loss of contractility; the extent of the infarction correlates with the severity
of HF. Left-sided heart failure is caused by myocardial ischemia. Ineffective
right ventricular contraction, pulmonary embolus, and cystic fibrosis cause
right-sided heart failure.
QUESTION 35: A client arrives at the ED with an exacerbation of left-sided heart failure and
reports shortness of breath. Which is the priority nursing intervention?
Correct Response: Assess oxygen saturation
Explanation: Assessment is priority to determine the severity of the exacerbation. It is

important to assess the oxygen saturation in a client with heart failure
because below-normal oxygen saturation can be life-threatening. Treatment
options vary according to the severity of the client’s condition and may
include supplemental oxygen, oral and IV medications, major lifestyle
changes, implantation of cardiac devices, and surgical approaches. The
overall goal of treatment of heart failure is to relieve symptoms and reduce
the workload on the heart by reducing afterload and preload.
QUESTION 36: A client who was admitted to the hospital with a diagnosis of
thrombophlebitis 1 day ago suddenly reports chest pain and shortness of
breath and is visibly anxious. The nurse immediately assesses the client for
other signs and symptoms of
Correct Response: pulmonary embolism.
Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused

by blood clots in the lungs. This disorder poses a particular threat to people
with cardiovascular disease. Blood clots that form in the deep veins of the
legs and embolize to the lungs can cause a pulmonary infarction, whereby
emboli mechanically obstruct the pulmonary vessels, cutting off the blood
supply to sections of the lung. Clinical indicators of pulmonary embolism can
vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
QUESTION 37: Which action will the nurse include in the plan of care for a client admitted
with acute decompensated heart failure (ADHF) who is receiving milrinone?
Correct Response: Monitor blood pressure frequently
Explanation: Milrinone is a phosphodiesterase inhibitor that delays the release of calcium

from intracellular reservoirs and prevents the uptake of extracellular calcium
by the cells. This promotes vasodilation, resulting in decreased preload and
afterload and reduced cardiac workload. Milrinone is administered
intravenously to clients with severe HF, including those who are waiting for a
heart transplant. Because the drug causes vasodilation, the client’s blood
pressure is monitored before administration because if the client is
hypovolemic the blood pressure could drop quickly. The major side effects are
hypotension and increased ventricular dysrhythmias. Blood pressure and the
electrocardiogram (ECG) are monitored closely during and after infusions of
milrinone.
QUESTION 38: A nurse caring for a client recently admitted to the ICU observes the client
coughing up large amounts of pink, frothy sputum. Lung auscultation reveals
course crackles to lower lobes bilaterally. Based on this assessment, the nurse
recognizes this client is developing
Correct Response: decompensated heart failure with pulmonary edema.
Explanation: Large quantities of frothy sputum, which is sometimes pink or tan (blood
tinged), may be produced, indicating acute decompensated HF with
pulmonary edema.
QUESTION 39: The nurse understands that a client with which cardiac arrhythmia is most at
risk for developing heart failure?
Correct Response: Atrial fibrillation
Explanation: Cardiac dysrhythmias such as atrial fibrillation may either cause or result
from heart failure; in both instances, the altered electrical stimulation
impairs myocardial contraction and decreases the overall efficiency of
myocardial function.
Quiz Stats

Answer Key
QUESTION 1: Which term refers to leg pain that is brought on by walking and caused by
arterial insufficiency?
Correct Response: Intermittent claudication
Explanation: Intermittent claudication is leg pain that is brought on by exercise and

relieved by rest. Dyspnea is difficulty breathing and is subjective. Orthopnea
is an inability to breathe except in the upright (sitting) position.
Thromboangiitis obliterans is a peripheral vascular disease also known as
Buerger disease.
QUESTION 2: Approximately what percentage of the arterial lumen must be obstructed

before intermittent claudication is experienced?
Correct Response: 50
Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area
must be obstructed before intermittent claudication is experienced.
QUESTION 3: Which is a characteristic of arterial insufficiency?
Correct Response: Diminished or absent pulses
Explanation: A diminished or absent pulse is a characteristic of arterial insufficiency.

Venous characteristics include superficial ulcer formation, an aching and
cramping pain, and presence of pulses.
QUESTION 4: Which aneurysm occurs as a result of infection at arterial suture or graft

sites?
Correct Response: Anastomotic
Explanation: An anastomotic aneurysm occurs as a result of infection, arterial wall failure,

and suture or graft failure. Dissection results from a rupture in the intimal
layer, resulting in bleeding between the intimal and medial layers of the
arterial wall. Saccular aneurysms collect blood in the weakened outpouching.
In a false aneurysm, the mass is actually a pulsating hematoma.
QUESTION 5: Which term refers to enlarged, red, and tender lymph nodes?
Correct Response: Lymphadenitis
Explanation: Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph

nodes. Lymphangitis is acute inflammation of the lymphatic channels.
Lymphedema is demonstrated by swelling of tissues in the extremities
because of an increased quantity of lymph that results from an obstruction of
lymphatic vessels. Elephantiasis refers to a condition in which chronic
swelling of the extremity recedes only slightly with elevation.
QUESTION 6: Which aneurysm results in bleeding into the layers of the arterial wall?
Correct Response: Dissecting
Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding
between the intimal and medial layers of the arterial wall. Saccular
aneurysms collect blood in the weakened outpouching. In a false aneurysm,
the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs
as a result of infection at arterial suture or graft sites.
QUESTION 7: The nurse teaches the client with peripheral vascular disease (PVD) to refrain
from smoking because nicotine
Correct Response: causes vasospasm.
Explanation: Nicotine causes vasospasm and can thereby dramatically reduce circulation to
the extremities. Nicotine has stimulant effects. Nicotine does not suppress
cough; rather, smoking irritates the bronchial tree, causing coughing. Nicotine
does not cause diuresis.
QUESTION 8: The term for a diagnostic test that involves injection of a contrast media into
the venous system through a dorsal vein in the foot is
Correct Response: contrast phlebography.
Explanation: When a thrombus exists, an x-ray image will disclose an unfilled segment of a
vein. Air plethysmography quantifies venous reflux and calf muscle pump
ejection. In lymphangiography, contrast media are injected into the lymph
system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into
the lymph system.
QUESTION 9: Which observation regarding ulcer formation on the client's lower extremity
indicates that the ulcer is a result of venous insufficiency?
Correct Response: Border of the ulcer is irregular
Explanation: The border of an ulcer caused by arterial insufficiency is circular. Superficial

venous insufficiency ulcers cause minimal pain. The base of a venous
insufficiency ulcer shows a beefy red to fibrinous yellow color. Venous
insufficiency ulcers are usually superficial.
QUESTION 10: Which term refers to a muscular, cramplike pain in the extremities

consistently reproduced with the same degree of exercise and relieved by
rest?
Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. An

aneurysm is a localized sac of an artery wall formed at a weak point in the
vessel. A bruit is the sound produced by turbulent blood flow through an
irregular, tortuous, stenotic, or dilated vessel. Ischemia is a term used to
denote deficient blood supply.
QUESTION 11: What should the nurse do to manage the persistent swelling in a client with
severe lymphangitis and lymphadenitis?
Correct Response: Teach the client how to apply an elastic sleeve
Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling,

the nurse teaches the client how to apply an elastic sleeve or stocking. The
nurse informs the physician if the client's temperature remains elevated. The
nurse recommends elevating the area to reduce the swelling and provides
warmth to promote comfort and to enhance circulation.
QUESTION 12: What symptoms should the nurse assess for in a client with lymphedema as a
result of impaired nutrition to the tissue?
Correct Response: Ulcers and infection in the edematous area
Explanation: In a client with lymphedema, the tissue nutrition is impaired as a result of the
stagnation of lymphatic fluid, leading to ulcers and infection in the
edematous area. Later, the skin also appears thickened, rough, and
discolored. Scaring does not occur in clients with lymphedema. Cyanosis is a
bluish discoloration of the skin and mucous membranes.
QUESTION 13: Which diagnostic test is used to quantify venous reflux and calf muscle pump
ejection?
Correct Response: Air plethysmography
Explanation: Air plethysmography is used to quantify venous reflux and calf muscle pump
action. Contrast phlebography involves injecting a radiopaque contrast agent
into the venous system. Lymphoscintigraphy is done when a radioactively
labeled colloid is injected subcutaneously in the second interdigital space.
The extremity is then exercised to facilitate the uptake of the colloid by the
lymphatic system, and serial images are obtained at preset intervals.
Lymphoangiography provides a way to detect lymph node involvement
resulting from metastatic carcinoma, lymphoma, or infection in sites that are
otherwise inaccessible to the examiner except by surgery.
QUESTION 14: In a client with a bypass graft, the distal outflow vessel must have at least
what percentage patency for the graft to remain patent?
Explanation: The distal outflow vessel must be at least 50% patent for the graft to remain
patent.
QUESTION 15: Which statement is accurate regarding Reynaud disease?
Correct Response: Episodes may be triggered by unusual sensitivity to cold.
Explanation: Episodes of Reynaud disease may be triggered by emotional factors or by

unusual sensitivity to cold. The disease is most common in women between 16
and 40 years of age. It is generally unilateral and affects only one or two
digits.
QUESTION 16: Which risk factor is related to venous stasis for deep vein thrombosis (DVT)
and pulmonary embolism (PE)?
Correct Response: Obesity
Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma,
pacing wires, and surgery are related to endothelial damage as a risk factor
for DCAT and PE.
QUESTION 17: Which class of medication lyses and dissolves thrombi?
Correct Response: Fibrinolytic
Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of

clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not
lyse or dissolve thrombi.
QUESTION 18: A nurse is teaching a client newly diagnosed with arterial insufficiency. Which
term should the nurse use to refer to leg pain that occurs when the client is
walking?
Explanation: Intermittent claudication is leg pain that is brought on by exercise and

relieved by rest. Dyspnea is difficulty breathing and is subjective. Orthopnea
is the inability to breathe except in the upright (sitting) position.
Thromboangiitis obliterans is a peripheral vascular disease also known as
Buerger disease.
QUESTION 19: What symptoms should the nurse assess for in a client with lymphedema as a
result of impaired nutrition to the tissue?
Correct Response: Ulcers and infection in the edematous area
Explanation: In a client with lymphedema, the tissue nutrition is impaired because of the
stagnation of lymphatic fluid, leading to ulcers and infection in the
edematous area. Later, the skin also appears thickened, rough, and
discolored. Scarring does not occur in clients with lymphedema. Cyanosis is a
bluish discoloration of the skin and mucous membranes.
QUESTION 20: What should the nurse do to manage persistent swelling in a client with
severe lymphangitis and lymphadenitis?
Correct Response: Teach the client how to apply a graduated compression stocking.
Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling,

the nurse teaches the client how to apply a graduated compression stocking.
The nurse informs the physician if the client's temperature remains elevated.
The nurse recommends elevating the area to reduce the swelling and provides
warmth to promote comfort and to enhance circulation.
QUESTION 21: A client in the emergency department states, “I have always taken a morning
walk, but lately my leg cramps and hurts after just a few minutes of walking.
The pain goes away after I stop walking, though.” Based on this statement,
which priority assessment should the nurse complete?
Correct Response: Attempt to palpate the dorsalis pedis and posterior tibial pulses.
Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The

nurse should assess for other clinical manifestations of peripheral arterial
disease in a client who describes intermittent claudication. A thorough
assessment of the client’s skin color and temperature and the character of
the peripheral pulses are important in the diagnosis of arterial disorders.
QUESTION 22: Which observation regarding ulcer formation on the client’s lower extremity
indicates to the nurse that the ulcer is a result of venous insufficiency?
Correct Response: Large and superficial
Explanation: Ulcerations are in the area of the medial or lateral malleolus (gaiter area)
and are typically large, superficial, and highly exudative. Superficial venous
insufficiency ulcers cause minimal pain. The base of a venous insufficiency
ulcer shows a beefy red to yellow fibrinous color.
QUESTION 23: The term for a diagnostic test that involves injection of a contrast media into
the venous system through a dorsal vein in the foot is
Correct Response: contrast phlebography.
Explanation: Also known as venography, contrast phlebography involves injecting a

radiopaque contrast agent into the venous system. If a thrombus exists, the x-
ray image reveals an unfilled segment of vein in an otherwise completely
filled vein. Air plethysmography quantifies venous reflux and calf muscle
pump ejection. In lymphangiography, contrast media are injected into the
lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is
injected into the lymph system.
QUESTION 24: The nurse teaches the client with peripheral vascular disease (PVD) to refrain
from smoking because nicotine causes
Correct Response: vasospasm.
Explanation: Nicotine causes vasospasm and can thereby dramatically reduce circulation to
the extremities. Tobacco smoke also impairs transport and cellular use of
oxygen and increases blood viscosity. Clients with arterial insufficiency who
smoke or chew tobacco must be fully informed of the effects of nicotine on
circulation and be encouraged to stop.
QUESTION 25: A client in the ED has a 5-cm thoracic aortic aneurysm that was discovered
during a routine chest x-ray. When obtaining the client's history, which
symptoms will it be most important for the nurse to ask about?
Correct Response: Hoarse voice and difficulty swallowing
Explanation: Symptoms are dyspnea, the result of pressure of the aneurysm sac against the
trachea, a main bronchus, or the lung itself; cough, frequently paroxysmal
and with a brassy quality; hoarseness, stridor, or weakness or complete loss of
the voice (aphonia), resulting from pressure against the laryngeal nerve; and
dysphagia (difficulty in swallowing) due to impingement of the aneurysm on
the esophagus.
QUESTION 26: A nurse is completing an assessment on a client and discovers an enlarged,

red, and tender lymph node. The nurse will describe and document the lymph
node using which term?
Correct Response: Lymphadenitis
Explanation: Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph

nodes. Lymphangitis is acute inflammation of the lymphatic channels.
Lymphedema is demonstrated by swelling of tissues in the extremities
because of an increased quantity of lymph that results from an obstruction of
lymphatic vessels. Elephantiasis refers to a condition in which chronic
swelling of the extremity recedes only slightly with elevation.
QUESTION 27: A nurse is changing a dressing on an arterial suture site. The site is red, with
foul-smelling drainage. Based on these symptoms, the nurse is aware to
monitor for which type of aneurysm?
Correct Response: Anastomotic
Explanation: An anastomotic aneurysm occurs as a result of infection at arterial suture or

graft sites. Dissection results from a rupture in the intimal layer, resulting in
bleeding between the intimal and medial layers of the arterial wall. Saccular
aneurysms collect blood in the weakened outpouching. In a false aneurysm,
the mass is actually a pulsating hematoma.
QUESTION 28: The nurse assessing a client who has arterial insufficiency of the legs and an
ulcer on the left great toe would expect to find which characteristic?
Correct Response: Diminished or absent pulses
Explanation: Occlusive arterial disease impairs blood flow and can reduce or obliterate
palpable pulsations in the extremities. A diminished or absent pulse is a
characteristic of arterial insufficiency.
QUESTION 29: A nursing instructor is discussing the diagnosis of intermittent claudication

with students. To determine whether the students understand the
pathophysiology of the disease, the instructor asks, “What percentage of the
arterial lumen must be obstructed before intermittent claudication is
experienced?” What answer should the students give?
Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area
must be obstructed before intermittent claudication is experienced.
QUESTION 30: The nurse knows which diagnostic test isused to document the anatomic site
of reflux and provides a quantitative measure of the severity of valvular
reflux?
Correct Response: Duplex ultrasound scan
Explanation: Diagnostic tests for varicose veins include the duplex ultrasound scan, which
documents the anatomic site of reflux and provides a quantitative measure of
the severity of valvular reflux. Contrast phlebography involves injecting a
radiopaque contrast agent into the venous system. Lymphoscintigraphy is
done when a radioactively labeled colloid is injected subcutaneously in the
second interdigital space. The extremity is then exercised to facilitate the
uptake of the colloid by the lymphatic system, and serial images are obtained
at preset intervals. Lymphoangiography provides a way to detect lymph node
involvement resulting from metastatic carcinoma, lymphoma, or infection in
sites that are otherwise inaccessible to the examiner except by surgery.
QUESTION 31: Which is a risk factor for venous disorders of the lower extremities?
Correct Response: Obesity
Explanation: Careful assessment is invaluable in detecting early signs of venous disorders

of the lower extremities. Clients with a history of varicose veins,
hypercoagulation, neoplastic disease, cardiovascular disease, or recent major
surgery or injury are at high risk. Other clients at high risk include those who
are obese or older adults and women taking oral contraceptives.
QUESTION 32: Which class of medication lyses and dissolves thrombi?
Correct Response: Fibrinolytic
Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of

clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not
lyse or dissolve thrombi.
QUESTION 33: A client admitted to the medical-surgical unit with a venous

thromboembolism (VTE) is started on enoxaparin and warfarin. The client
asks the nurse why two medications are needed. Which response by the nurse
is accurate?
Correct Response: “The enoxaparin will work immediately, but the warfarin takes several days
to achieve its full effect.”
Explanation: Oral anticoagulants such as warfarin are monitored by the prothrombin time
(PT) or the international normalized ratio (INR). Because the full
anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually
administered concurrently with heparin until desired anticoagulation has been
achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).
QUESTION 34: A client is receiving enoxaparin and warfarin therapy for a venous
thromboembolism (VTE). Which laboratory value indicates that
anticoagulation is adequate and enoxaparin can be discontinued?
Correct Response: International normalized ratio (INR) is 2.5.
Explanation: Oral anticoagulants such as warfarin are monitored by PT or the INR. Because
the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is
usually administered concurrently with heparin until desired anticoagulation
has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0
to 3.0)
QUESTION 35: A client is being discharged home with a venous stasis ulcer on the right lower
leg. Which topic will the nurse include in client teaching before discharge?
Correct Response: Application of graduated compression stockings
Explanation: Graduated compression stockings usually are prescribed for clients with
venous insufficiency. The required pressure gradient is determined by the
amount and severity of venous disease. Graduated compression stockings are
designed to apply 100% of the prescribed pressure gradient at the ankle and
pressure that decreases as the stocking approaches the thigh, reducing the
caliber of the superficial veins in the leg and increasing flow in the deep
veins. These stockings may be knee high, thigh high, or pantyhose.
QUESTION 36: A community health nurse teaches a group of older adults about modifiable
risk factors that contribute to the development of peripheral arterial disease
(PAD). The nurse knows that the teaching was effective based on which
statement?
Correct Response: “I will need to stop smoking because the nicotine causes less blood to flow to
my hands and feet.”
Explanation: The use of tobacco products may be one of the most important risk factors in
the development of atherosclerotic lesions. Nicotine in tobacco decreases
blood flow to the extremities and increases heart rate and blood pressure by
stimulating the sympathetic nervous system. This causes vasoconstriction,
thereby decreasing arterial blood flow. It also increases the risk of clot
formation by increasing the aggregation of platelets.
QUESTION 37: A nurse is caring for a client following an arterial vascular bypass graft in the
leg. What should the nurse plan to assess over the next 24 hours?
Correct Response: Peripheral pulses every 15 minutes after surgery
Explanation: The primary objective in the postoperative period is to maintain adequate

circulation through the arterial repair. Pulses, Doppler assessment, color and
temperature, capillary refill, and sensory and motor function of the affected
extremity are checked and compared with those of the other extremity;
these values are recorded initially every 15 minutes and then at progressively
longer intervals if the client’s status remains stable.
QUESTION 38: The nurse completes discharge teaching for a client following a femoral-to-
popliteal bypass graft. What response by the client indicates that the
teaching was effective?
Correct Response: “I will call if I develop any coldness, numbness, tingling, or pain in the
surgical leg.”
Explanation: The nurse ensures that the client has the knowledge and ability to assess for
any postoperative complications such as infection, occlusion of the artery or
graft, and decreased blood flow. Coldness, numbness, tingling, and pain are
signs of peripheral arterial occlusion, and immediate intervention is required.
QUESTION 39: A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe
lower back pain. Which is the most likely cause?
Correct Response: The aneurysm may be preparing to rupture.
Explanation: Signs of impending rupture include severe back or abdominal pain, which may
be persistent or intermittent. Abdominal pain is often localized to the middle
or lower abdomen to the left of the midline. Low-back pain may be present
because of pressure of the aneurysm on the lumbar nerves. Indications of a
rupturing AAA include constant, intense back pain; falling blood pressure; and
decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A
retroperitoneal rupture of an aneurysm may result in hematomas in the
scrotum, perineum, flank, or penis.
Quiz Stats

Answer Key
QUESTION 1: According to the classification of hypertension diagnosed in older adults,

hypertension that can be attributed to an underlying cause is termed
Correct Response: secondary.
Explanation: Secondary hypertension may be caused by a tumor of the adrenal gland (e.g.,
pheochromocytoma). Primary, or essential, hypertension has no known
underlying cause. Isolated systolic hypertension is demonstrated by readings
in which the systolic pressure exceeds 140 mm Hg and the diastolic
measurement is normal or near normal (less than 90 mm Hg).
QUESTION 2: When measuring blood pressure in each arm of a healthy adult, the nurse
recognizes that the pressures
Correct Response: differ no more than 5 mm Hg between arms.
Explanation: Normally, in the absence of disease of the vasculature, arm pressures differ
by no more than 5 mm Hg. The pressures in each arm do not have to be equal
to be considered normal. Pressures that vary more than 10 mm Hg between
arms are an abnormal finding. The left arm pressure is not anticipated to be
higher than the right as a normal anatomical variant.
QUESTION 3: Nurses should implement measures to relieve emotional stress for clients with
hypertension because the reduction of stress
Correct Response: decreases the production of neurotransmitters that constrict peripheral

arterioles.
Explanation: Reduced stress decreases the production of neurotransmitters that constrict

peripheral arterioles. Reduced stress may assist in reducing blood volume and
resistance to the heart.
QUESTION 4: It is appropriate for the nurse to recommend smoking cessation for clients
with hypertension because nicotine
Correct Response: increases the heart rate, constricts arterioles, and reduces the heart's ability
to eject blood.
Explanation: The nurse recommends smoking cessation for clients with hypertension
because nicotine raises the heart rate, constricts arterioles, and reduces the
heart's ability to eject blood. Reduced oral fluids decrease the circulating
blood volume.
QUESTION 5: It is important for the nurse to encourage the client to rise slowly from a
sitting or lying position because gradual changes in position
Correct Response: provide time for the heart to increase the rate of contraction to resupply
oxygen to the brain.
Explanation: It is important for the nurse to encourage the client to rise slowly from a
sitting or lying position because gradual changes in position provide time for
the heart to increase its rate of contraction to resupply oxygen to the brain,
not blood pressure or heart rate.
QUESTION 6: Which condition contributes to secondary hypertension?
Correct Response: Arterial vasoconstriction
Explanation: Secondary hypertension may accompany any primary condition that affects
fluid volume or renal function or causes arterial vasoconstriction. Calcium
deficiency or acid-based imbalance does not contribute to hypertension.
QUESTION 7: Which term is refers to hypertension in which blood pressure that is

controlled with therapy becomes uncontrolled (abnormally high) when the
therapy is discontinued?
Correct Response: Rebound
Explanation: Rebound hypertension may precipitate a hypertensive crisis. Essential or

primary hypertension denotes high blood pressure from an unidentified
source. Secondary hypertension denotes high blood pressure from an
identified cause, such as renal disease.
QUESTION 8: Officially, hypertension is diagnosed when the client demonstrates a systolic

blood pressure greater than ______ mm Hg and a diastolic blood pressure
greater than _____ mm Hg over a sustained period.
Correct Response: 140, 90
Explanation: According to the categories of blood pressure levels established by the JNC
VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159,
or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic
falls within the prehypertension classification range for an adult. Pressures of
110 systolic and 60 diastolic, and of 120 systolic and 70 diastolic, fall within
the normal range for an adult.
QUESTION 9: The nurse teaches the client which guideline regarding lifestyle

modification for hypertension?
Correct Response: Maintain adequate dietary intake of potassium
Explanation: In general, one serving of a potassium-rich food such as banana, kale,

broccoli, or orange juice will meet the daily need for potassium. The client
should be guided to stop smoking. The general guideline is to advise the
client to increase aerobic activity to 30 to 45 minutes most days of the week.
In general, alcohol intake should be limited to no more than 1 oz ethanol/day.
QUESTION 10: Which diuretic medication conserves potassium?
Explanation: Spironolactone is known as a potassium-sparing diuretic. Furosemide causes

loss of potassium from the body. Chlorothiazide and chlorthalidone cause mild
hypokalemia.
QUESTION 11: Which adrenergic inhibitor acts directly on the blood vessels, producing
vasodilation?
Correct Response: Prazosin
Explanation: Prazosin is a peripheral vasodilator acting directly on the blood vessels. It is

not used in angina and coronary artery disease, however, because it induces
tachycardia if not preceded by administration of propranolol and a diuretic.
Reserpine impairs synthesis and reuptake of norepinephrine. Propranolol
blocks the beta-adrenergic receptors of the sympathetic nervous system,
especially the sympathetics to the heart, producing a slower heart rate and
lowered blood pressure. Clonidine acts through the central nervous system,
apparently through centrally mediated alpha-adrenergic stimulation in the
brain, reducing blood pressure.
QUESTION 12: Which term describes high blood pressure from an identified cause, such as
renal disease?
Correct Response: Secondary hypertension
Explanation: Secondary hypertension is high blood pressure from an identified cause, such
as renal disease. Primary hypertension denotes high blood pressure form an
unidentified source. Rebound hypertension is pressure that is controlled with
therapy and becomes uncontrolled (abnormally high) when that therapy is
discontinued. A hypertensive emergency is a situation in which blood pressure
is severely elevated and there is evidence of actual or probable target organ
damage.
QUESTION 13: A systolic blood pressure of 135 mm Hg would be classified as
Correct Response: prehypertension.
Explanation: A systolic blood pressure of 135 mm Hg is classified as prehypertension. A

systolic BP less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg
is stage I hypertension. A systolic BP greater than or equal to 160 is classified
as stage 2 hypertension.
QUESTION 14: Which diagnostic method is recommended to determine whether left

ventricular hypertrophy has occurred?
Correct Response: Echocardiography
Explanation: An echocardiogram is recommended method of determining whether

hypertrophy has occurred. Electrocardiography and blood chemistry are part
of the routine workup. Renal damage may be suggested by elevations in blood
urea nitrogen and creatinine concentrations.
QUESTION 15: Which term describes a situation in which blood pressure is very elevated but
there is no evidence of impending or progressive target organ damage?
Correct Response: Hypertensive urgency
Explanation: Hypertensive urgency is a situation in which blood pressure is severely

elevated but there is no evidence of actual or probable target organ damage.
A hypertensive emergency is a situation in which blood pressure is severely

elevated and there is evidence of actual or probable target organ damage.
Primary hypertension denotes high blood pressure from an unidentified
source. Secondary hypertension is high blood pressure from an identified
cause, such as renal disease.
QUESTION 16: A diastolic blood pressure of 90 mm Hg is classified as
Correct Response: stage 1 hypertension.
Explanation: A diastolic BP of 80 to 80 mm Hg is classified as prehypertension. A diastolic

BP less than 80 mm Hg is normal. A diastolic BP of 90 to 99 mm Hg is stage I
hypertension. A diastolic BP of 100 mm Hg or above is classified as stage 2
hypertension.
QUESTION 17: A blood pressure (BP) of 140/90 mm Hg is considered to be
Correct Response: hypertension.
Explanation: A BP of 140/90 mm Hg or higher is hypertension. A blood pressure less than

120/80 mm Hg is considered normal. A BP of 120 to 139/80 to 89 mm Hg is
prehypertension. Hypertensive emergency is a situation in which BP is
severely elevated and there is evidence of actual or probable target organ
damage.
QUESTION 18: Approximately what percentage of adults in the United States have
hypertension?
Explanation: About 32.6% of the adults in the United States have hypertension.
QUESTION 19: Which describes a situation in which blood pressure is severely elevated and
there is evidence of actual or probable target organ damage?
Correct Response: Hypertensive emergency
Explanation: A hypertensive emergency is a situation in which blood pressure is severely

elevated and there is evidence of actual or probable target organ damage.
Hypertensive urgency is a situation in which blood pressure is severely
elevated but there is no evidence of actual or probable target organ damage.
Secondary hypertension is high blood pressure from an identified cause, such
as renal disease. Primary hypertension denotes high blood pressure from an

unidentified source.
QUESTION 20: According to the DASH diet, how many servings of vegetables should a person
consume each day?
Correct Response: 4 or 5
Explanation: Four or five servings of vegetables are recommended in the DASH diet. The
diet recommends two or fewer servings of lean meat, fish, and poultry; two
or three servings of low-fat or fat-free dairy foods; and seven or eight
servings of grains and grain products.
QUESTION 21: As recommended follow-up for a client initially diagnosed with

prehypertension, the client should get his or her blood pressure rechecked
within which time frame?
Correct Response: Recheck in 1 year
Explanation: A client with an initial blood pressure (BP) in the prehypertension range
should have his or her BP rechecked in 1 year. A normal BP should be
rechecked in 2 years. Stage 1 hypertension should be confirmed and followed
up within 2 months. Stage 2 hypertension should be evaluated or referred to a
source of care within 1 month.
QUESTION 22: Hypertension that can be attributed to an underlying cause is termed
Correct Response: secondary hypertension.
Explanation: Secondary hypertension may be caused by a tumor of the adrenal gland (e.g.,
pheochromocytoma). Primary, or essential, hypertension has no known
underlying cause. Isolated systolic hypertension is demonstrated by readings
in which the systolic pressure exceeds 140 mm Hg and the diastolic
measurement is normal or near normal (less than 90 mm Hg).
QUESTION 23: When measuring the blood pressure in each arm of a healthy adult client, the
nurse recognizes that which statement is true?
Correct Response: Pressures should not differ more than 5 mm Hg between arms.
Explanation: Normally, in the absence of any disease of the vasculature, arm pressures
differ by no more than 5 mm Hg. The pressures in each arm do not have to be
equal to be considered normal. Pressures that vary more than 10 mm Hg
between arms are an abnormal finding. The left arm pressure is not
anticipated to be higher than the right as a normal anatomic variant.
QUESTION 24: It is important for the nurse to encourage the cltient diagnosed with
hypertension to rise slowly from a sitting or lying position because gradual
changes in position
Correct Response: provide time for the heart to increase the rate of contraction to resupply
oxygen to the brain.
Explanation: It is important for the nurse to encourage the client to rise slowly from a
sitting or lying position because gradual changes in position provide time for
the heart to increase its rate of contraction to resupply oxygen to the brain,
not blood pressure or heart rate.
QUESTION 25: The nurse is caring for a client newly diagnosed with secondary hypertension.
Which condition contributes to the development of secondary hypertension?
Correct Response: Renal disease
Explanation: Secondary hypertension occurs when a cause for the high blood pressure can
be identified. These causes include renal parenchymal disease, narrowing of
the renal arteries, hyperaldosteronism (mineralocorticoid hypertension),
pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa),
and coarctation of the aorta. High blood pressure can also occur with
pregnancy; women who experience high blood pressure during pregnancy are
at increased risk of ischemic heart disease, heart attack, stroke, kidney
disease, diabetes, and death from heart attack. Calcium deficiency or acid-
based imbalance does not contribute to hypertension.
QUESTION 26: The nurse teaches the client which guidelines regarding lifestyle
modifications for hypertension?
Correct Response: Maintain adequate dietary intake of fruits and vegetables
Explanation: Guidelines include adopting the Dietary Approaches to Stop Hypertension

(DASH) eating plan: consume a diet rich in fruits, vegetables, and low-fat
dairy products and reduced amounts of saturated and total fat; reduce
dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g
sodium chloride); engage in regular aerobic physical activity such as brisk
walking (at least 30 min/day, most days of the week); moderate alcohol
consumption, limiting consumption to no more than two drinks (eg, 24 oz
beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no
more than one drink per day in women and lighter-weight people. Tobacco
should be avoided because anyone with high blood pressure is already at

increased risk for heart disease, and smoking amplifies this risk.
QUESTION 27: The nurse is caring for a client who is prescribed diuretic medication for the
treatment of hypertension. The nurse recognizes that which
medication conserves potassium?
Explanation: Spironolactone is known as a potassium-sparing diuretic. Furosemide causes

loss of potassium from the body. Chlorothiazide and chlorthalidone cause mild
hypokalemia.
QUESTION 28: The nurse is caring for a patient with systolic blood pressure of 135 mm Hg.
This finding would be classified as
Correct Response: prehypertension.
Explanation: A systolic blood pressure of 135 mm Hg is classified as prehypertension. A

systolic BP less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg
is stage I hypertension. A systolic BP greater than or equal to 160 is classified
as stage II hypertension.
QUESTION 29: The nurse is teaching a client diagnosed with hypertension about the DASH
diet. How many servings of meat, fish, and poultry should the client consume
per day?
Correct Response: 2 or fewer
Explanation: Two or fewer servings of lean meat, fish, and poultry are recommended in the
DASH diet. The diet also recommends two or three servings of low-fat or fat-
free dairy foods, four or five servings of fruits and vegetables, and seven or
eight servings of grains and grain products.
QUESTION 30: Which condition(s) indicates target organ damage from

untreated/undertreated hypertension? Select all that apply.
Correct Response: Stroke

Heart failure
Retinal damage
Explanation: Target organs include the heart, kidney, brain, and eyes. Hyperlipidemia and
diabetes are risk factors for development of hypertension.
QUESTION 31: The nurse understands that client education related to antihypertensive
medication should include all instructions except
Correct Response: if a dosage of medication is missed, double up on the next one to catch up.
Explanation: Doubling doses could cause serious hypotension (HTN) and is not
recommended. Medications should be taken as prescribed. Hot baths,
strenuous exercise, and excessive alcohol are all vasodilators and should be
avoided. Many over-the-counter preparations can precipitate HTN. Stopping
antihypertensives abruptly can precipitate a severe hypertensive reaction and
is not recommended.
QUESTION 32: Choose the statements that correctly match the hypertensive medication with
its side effect. Select all that apply.
Correct Response: Direct vasodilators may cause headache and tachycardia.

With thiazide diuretics, monitor serum potassium concentration.
Explanation: Thiazide diuretics may deplete potassium; many clients will need potassium
supplementation. Direct vasodilators may cause headache and increased
heart rate. Adrenergic inhibitors can cause sedation and fatigue. Beta-
blockers may induce decreased heart rate; pulse rate should be assessed
before administration. Angiotensin-converting enzyme inhibitors can induce a
mild to severe dry cough.
QUESTION 33: A 35-year-old client has been diagnosed with hypertension. The client is a
stock broker, smokes daily, and has diabetes. During a follow-up appointment,
the client states that regular visits to the doctor just to check blood pressure
(BP) are cumbersome and time consuming. As the nurse, which aspect of
client teaching would you recommend?
Correct Response: Purchasing a self-monitoring BP cuff
Explanation: Because this client finds visiting the doctor time-consuming just for a BP
reading, as the nurse, you can suggest the use of an automatic cuff at a local
pharmacy, or purchasing a self-monitoring cuff. Discussing methods to reduce
stress, advising smoking cessation, and achieving glycemic control would
constitute client education in managing hypertension.
QUESTION 34: A 66-year-old client presents to the emergency department reporting severe
headache and mild nausea for the past 6 hours. Upon assessment, the client’s
BP is 210/120 mm Hg. The client has a history of hypertension and takes 1.0
mg clonidine twice daily. Which question is most important for the nurse to
ask the client next?
Correct Response: “Have you taken your prescribed clonidine today?”
Explanation: The nurse must ask whether the client has taken his prescribed clonidine.
Clients need to be informed that rebound hypertension can occur if
antihypertensive medications are suddenly stopped. Specifically, a side effect
of clonidine is rebound or withdrawal hypertension. Although the other
questions may be asked, it is most important to inquire whether the client
has taken the prescribed hypertension medication given the client’s severely
elevated BP.
QUESTION 35: A client is admitted to the intensive care unit (ICU) with a diagnosis of
hypertension emergency/crisis. The client’s blood pressure (BP) is 200/130
mm Hg. The nurse is preparing to administer IV nitroprusside. Upon
assessment, which finding requires immediate intervention by the nurse?
Correct Response: Numbness and weakness in the left arm
Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that

require prompt treatment in an intensive care setting because of the serious
target organ damage that may occur. The finding of numbness and weakness
in left arm may indicate the client is experiencing neurological symptoms
associated with an ischemic stroke because of the severely elevated BP;
immediate intervention is required. Urine output of 40 mL/h is within normal
limits. The other findings are likely caused by the hypertension and require
intervention, but they do not require action as urgently as the neurologic
changes.
QUESTION 36: A 55-year-old client newly diagnosed with hypertension returns to the
physician’s office for a routine follow-up appointment after several months of
treatment with metoprolol. During the initial assessment, the nurse records
the client’s blood pressure (BP) as 180/90 mm Hg. The client states that the
medicatoin is not taken as prescribed. Which is the best response by the
nurse?
Correct Response: “The medication you were prescribed may cause sexual dysfunction; are you
experiencing this side effect?”
Explanation: The nurse needs to understand why the client is not taking the medication.
Metoprolol is a beta-blocker. All clients should be informed that beta-blockers
might cause sexual dysfunction and that other medications are available if
problems with sexual function occur. The other statements, although true,
are not therapeutic and would not elicit the reason why the client was not
taking the medication as prescribed.
QUESTION 37: The nurse is caring for a client prescribed bumetanide for the treatment of
stage 2 hypertension. Which finding indicates the client is experiencing an
adverse effect of the medication?
Correct Response: Serum potassium value of 3.0 mEq/L
Explanation: Bumetanide is a loop diuretic that can cause fluid and electrolyte imbalances.
Clients taking these medications may experience a low serum potassium
concentration. ECG changes associated with an elevated serum potassium
concentration include peaked T waves. Diuresis is a desired effect
postadministration of bumetanide. The serum glucose concentration is
elevated and requires intervention; however, this elevation is not associated
with the administration of bumetanide.
QUESTION 38: The nurse is administering medications on a medical-surgical unit. A client is

ordered to receive 40 mg oral nadolol for the treatment of hypertension.
Before administering the medication, the nurse should
Correct Response: check the client’s heart rate.
Explanation: Nadolol is a beta-blocker. A desired effect of this medication is to reduce the

pulse rate in clients with tachycardia and elevated blood pressure (BP). The
nurse should check the client’s heart rate (HR) before administering nadolol
to ensure that the pulse is not less than 60 beats per minute. The other
interventions are not indicated before administering a beta-blocker
medication.
QUESTION 39: The nurse is conducting a service project for a local elderly community group
on the topic of hypertension. The nurse will relay that which risk factors and
cardiovascular problems are related to hypertension? Select all that apply.
Correct Response: Age ≥65 in women

Smoking
Overweight/obesity
Explanation: Major risk factors (in addition to hypertension) include smoking, dyslipidemia
(high LDL, low high-density lipoprotein cholesterol), diabetes mellitus,
impaired renal function, obesity, physical inactivity, age (younger than 45
years for men, 65 years and older for women), and family history of
cardiovascular disease.
QUESTION 40: The nurse is caring for a client newly diagnosed with hypertension. Which
statement by the client indicates the need for further teaching?
Correct Response: “If I take my blood pressure and it is normal, I don’t have to take my blood
pressure pills.”
Explanation: The client needs to understand the disease process and how lifestyle changes
and medications can control hypertension. The client must take all
medications as directed. A normal blood pressure indicates the medication is
producing the desired effect. The other responses do not indicate the need
for further teaching.
QUESTION 41: The nurse understands that an overall goal of hypertension management is
that
Correct Response: there is no indication of target organ damage.
Explanation: Prolonged blood pressure elevation gradually damages blood vessels

throughout the body, particularly in target organs such as the heart, kidneys,
brain, and eyes. The overall goal of management is that the client does not
experience target organ damage. The desired effects of antihypertensives are
to maintain a normal blood pressure. Postural hypotension and sexual
dysfunction are side effects of certain antihypertension medications.
QUESTION 42: The nurse is caring for a client who has had 25 mg of oral hydrochlorothiazide
added to the medication regimen for the treatment of hypertension. Which
instruction should the nurse give the client?
Correct Response: “Increase the amount of fruits and vegetables you eat.”
Explanation: Thiazide diuretics cause loss of sodium, potassium, and magnesium. The
client should be encouraged to eat fruits and vegetables that are high in
potassium. Diuretics cause increased urination; the client should not take the
medication before going to bed. Thiazide diuretics to not cause dry mouth or
nasal congestion. Postural hypotension (side effect) may be potentiated by
alcohol.
QUESTION 43: Which statements are true when the nurse is measuring blood pressure (BP)?
Select all that apply.
Correct Response: The client should sit quietly while BP is being measured.
Using a BP cuff that is too small will give a higher BP measurement.
The client’s arm should be positioned at the level of the heart.
Explanation: These statements are all true when measuring a BP. When using a BP cuff that
is too large, the reading will be lower than the actual BP. The client should
avoid smoking cigarettes or drinking caffeine for 30 minutes before BP is

measured.
QUESTION 44: Which finding indicates that hypertension is progressing to target organ

damage?
Correct Response: Retinal blood vessel damage
Explanation: Symptoms suggesting that hypertension is progressing to the extent that

target organ damage is occurring must be detected early so that appropriate
treatment can be initiated. All body systems must be assessed to detect any
evidence of vascular damage. An eye examination with an ophthalmoscope is
important because retinal blood vessel damage indicates similar damage
elsewhere in the vascular system. The client is questioned about blurred
vision, spots in front of the eyes, and diminished visual acuity. The heart,
nervous system, and kidneys are also carefully assessed. A BUN concentration
of 12 mg/dL and urine output of 60 mL over 2 hours are normal findings. The
presence of pneumonia does not indicate target organ damage.
QUESTION 45: A 77-year-old client presents to the local community center for a blood
pressure (BP) screening; BP is recorded as 180/90 mm Hg. The client has a
history of hypertension but currently is not taking the prescribed medications.
Which question is most appropriate for the nurse to ask the client first?
Correct Response: “Why are you not taking your medications?”
Explanation: It is important for the nurse to first ascertain why the client is not taking
prescribed medications. Adherence to the therapeutic program may be more
difficult for older adults. The medication regimen can be difficult to
remember, and the expense can be a challenge. Monotherapy (treatment with
a single agent), if appropriate, may simplify the medication regimen and
make it less expensive. The other questions are appropriate, but the priority
is to determine why the medication regimen is not being followed.
Quiz Stats

Answer Key
QUESTION 1: Which statement best describes the function of fibrinogen?
Correct Response: Plays a key role in forming blood clots
Explanation: Fibrinogen, the largest share of plasma protein, plays a key role in forming
blood clots. It can be transformed from a liquid to fibrin, a solid that controls
bleeding. Globulins function primarily as immunologic agents by preventing or
modifying some types of infectious diseases. On the other hand, albumin
helps maintain the osmotic pressure that retains fluid in the vascular
compartment.
QUESTION 2: Which term describes the percentage of blood volume that consists of

erythrocytes?
Correct Response: Hematocrit
Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes.

Differentiation is the development of functions and characteristics that differ
from those of the parent stem cell. ESR is a laboratory test that measures the
rate of settling of red blood cells (RBCs); an elevated rate is indicative of
inflammation. Hemoglobin is the iron-containing protein of RBCs.
QUESTION 3: A client with severe anemia is admitted to the hospital. Because of religious
beliefs, the client is refusing blood transfusions. The nurse anticipates
pharmacologic therapy with which drug to stimulate the production of red
blood cells?
Correct Response: Epoetin alfa
Explanation: Erythropoietin (epoetin alfa) is an effective alternative treatment for clients

with chronic anemia secondary to diminished levels of erythropoietin. This
medication stimulates erythropoiesis.
QUESTION 4: A nurse is completing a detailed health history and assessment in the

electronic medical record (EMR) for a client with a disorder of the
hematopoietic system. Which symptom is the most commonly reported in
association with hematologic diseases?
Correct Response: Extreme fatigue
Explanation: When assessing a client with a disorder of the hematopoietic system, it is

essential to assess for the most common symptom in hematologic diseases,
which is extreme fatigue.
QUESTION 5: During a blood transfusion with packed red blood cells (RBCs), a client reports
chills, low back pain, and nausea. What priority action should the nurse take?
Correct Response: Discontinue the infusion immediately and maintain the IV line with normal
saline solution using new IV tubing
Explanation: The following steps are taken to determine the type and severity of the
reaction: Stop the transfusion. Maintain the IV line with normal saline solution
through new IV tubing, administered at a slow rate. Assess the client
carefully. Notify the physician. Continue to monitor the client’s vital signs and
respiratory, cardiovascular, and renal status. Notify the blood bank that a
suspected transfusion reaction has occurred. Send the blood container and
tubing to the blood bank for repeat typing and culture.
QUESTION 6: A nursing instructor is reviewing the role and function of stem cells in the
bone marrow with a group of nursing students. After providing the
explanation, the instructor asks the students to use their knowledge of
anatomy and physiology to determine an alternate way in which adults with
diseases that destroy marrow can resume production of blood cells. Which
explanation by the students is correct?
Correct Response: The liver and spleen can resume production of blood cells through
extramedullary haematopoiesis.
Explanation: In adults with disease that destroy marrow or cause fibrosis or scarring, the
liver and spleen can also resume production of blood cells through a process
known as extramedullary hematopoiesis.
QUESTION 7: Which is a symptom of severe thrombocytopenia?
Correct Response: Petechiae
Explanation: Clients with severe thrombocytopenia have petechiae, which are pinpoint
hemorrhagic lesions, usually more prominent on the trunk or anterior aspects
of the lower extremities.
QUESTION 8: A client comes into the emergency department reporting an enlarged tongue.
The tongue appears smooth and beefy red in color. The nurse also observes a
5-cm incision on the upper left quadrant of the abdomen. When questioned,
the client states, “I had a partial gastrostomy 2 years ago.” Based on this
information, the nurse attributes these symptoms to which problem?
Correct Response: Vitamin B12 deficiency
Explanation: Because vitamin B12 is found only in foods of animal origin, strict vegetarians
may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor
produced in the stomach. The vitamin B12–intrinsic factor complex is absorbed
in the distal ileum. Clients who have had a partial or total gastrectomy may
have limited amounts of intrinsic factor, and therefore the absorption of
vitamin B12 may be diminished. The effects of either decreased absorption or
decreased intake of vitamin B12 are not apparent for 2–4 years. This results in
megaloblastic anemia. Some symptoms are a smooth, beefy red, enlarged
tongue and cranial nerve deficiencies.
QUESTION 9: Which nursing intervention should be incorporated into the plan of care for a

client with impaired liver function and a low albumin concentration?
Correct Response: Monitor for edema at least once per shift
Explanation: Albumin is particularly important for the maintenance of fluid balance within
the vascular system. Capillary walls are impermeable to albumin, so its
presence in the plasma creates an osmotic force that keeps fluid within the
vascular space. Clients with impaired hepatic function may have low
concentrations of albumin, with a resultant decrease in osmotic pressure and
the development of edema.
QUESTION 10: A client with Hodgkin disease had a bone marrow biopsy yesterday and
reports aching at the biopsy site, rated a 5 (on a 1–10 scale). After assessing
the biopsy site, which nursing intervention is most appropriate?
Correct Response: Administer acetaminophen 500 mg po, as ordered
Explanation: After a marrow sample is obtained, pressure is applied to the site for several
minutes. The site is then covered with a sterile dressing. Most clients have no
discomfort after a bone marrow biopsy, but the site of a biopsy may ache for
1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen)
may be useful. Aspirin-containing analgesic agents should be avoided it the
immediate post-procedure period because they can aggravate or potentiate

bleeding.
QUESTION 11: A nurse is reviewing a client’s morning laboratory results and notes a left shift
in the band cells. Based on this result, the nurse can interpret that the client
Correct Response: may be developing an infection.
Explanation: Less mature granulocytes have a single-lobed, elongated nucleus and are
called band cells. Ordinarily, band cells account for only a small percentage
of circulating granulocytes, although their percentage can increase greatly
under conditions in which neutrophil production increases, such as infection.
An increased number of band cells is sometimes called a left shift or shift to
the left. Anemia refers to decreased red cell mass. Leukopenia refers to a
less-than-normal amount of white blood cells in circulation.
Thrombocytopenia refers to a lower-than-normal platelet count.
QUESTION 12: Which term refers to a form of white blood cell involved in immune response?
Correct Response: Lymphocyte
Explanation: Mature lymphocytes are the principal cells of the immune system, producing
antibodies and identifying other cells and organisms as “foreign.” Both B and
T lymphocytes respond to exposure to antigens. Granulocytes include
basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell
without central pallor, seen with hemolysis. A thrombocyte is a platelet.
QUESTION 13: The nurse is completing a pretransfusion assessment to determine a female

client's history of previous transfusions as well as previous reactions to
transfusions. Which is the most important information to obtain from this
client before the transfusion?
Correct Response: Number of pregnancies
Explanation: The history should include the type of reaction, its manifestations, the
interventions required, and whether any preventive interventions were used
in subsequent transfusions. The nurse assesses the number of pregnancies a
woman has had because a high number can increase her risk of reaction due
to antibodies developed from exposure to fetal circulation. Other concurrent
health problems should be noted, with careful attention paid to cardiac,
pulmonary, and vascular diseases.
QUESTION 14: Which type of lymphocyte is responsible for cellular immunity?
Correct Response: T lymphocyte
Explanation: T lymphocytes are responsible for delayed allergic reactions, rejection of

foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This
process is known as cellular immunity. B lymphocytes are responsible for
humoral immunity. A plasma cell secretes immunoglobulin. A basophil
contains histamine and is an integral part of hypersensivity reactions.
QUESTION 15: Which cell of hematopoiesis is responsible for the production of red blood
cells (RBCs) and platelets?
Correct Response: Myeloid stem cell
Explanation: The myeloid stem cell is responsible not only for all nonlymphoid white blood
cells, but also for the production of red blood cells and platelets. Lymphoid
cells produce either T or B lymphocytes. A monocyte is large WBC that
becomes a macrophage when is leaves the circulation and moves into body
tissues. A neutrophil is a fully mature WBC capable of phagocytosis.
QUESTION 16: Vitamin B and folic acid deficiencies are characterized by production of
abnormally large erythrocytes called
Correct Response: megaloblasts.
Explanation: Megaloblasts are abnormally large erythrocytes. Blast cells are primitive
WBCs. Mast cells are cells found in connective tissue involved in defense of
the body and coagulation. Monocytes are large WBCs that become
macrophages when they leave the circulation and move into body tissues.
QUESTION 17: Which is the major function of neutrophils?
Correct Response: Phagocytosis
Explanation: Once a neutrophil is released from the marrow into the circulation, it stays
there for only about 6 hours before it migrates into the body tissues to
perform its function of phagocytosis (ingestion and digestion of bacteria and
particles). Neutrophils die there within 1 to 2 days. T lymphocytes are
responsible for rejection of foreign tissue and destruction of tumor cells.
Plasma cells produce antibodies called immunoglobulins.
QUESTION 18: Which term refers to the percentage of blood volume that consists of
erythrocytes?
Correct Response: Hematocrit
Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes.

Differentiation is development of functions and characteristics that differ
from those of the parent stem cell. ESR is a laboratory test that measures the
rate of settling of RBCs; an elevated rate is indicative of inflammation.
Hemoglobin is the iron-containing protein of RBCs.
QUESTION 19: The nurse recognizes that the most common cause of iron deficiency anemia
in an adult is
Correct Response: bleeding.
Explanation: Iron deficiency in adults generally indicates blood loss (e.g., from bleeding in
the gastrointestinal (GI) tract or heavy menstrual flow). Lack of dietary iron is
rarely the sole cause of iron deficiency anemia in adults. The source of iron
deficiency should be investigated promptly because iron deficiency in an
adult may be a sign of bleeding in the GI tract or colon cancer.
QUESTION 20: The physician performs a bone marrow biopsy from the posterior iliac crest on
a client with pancytopenia. What intervention should the nurse perform after
the procedure?
Correct Response: Apply pressure over the site for 5–7 minutes
Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and
infection. The risk of bleeding is somewhat increased if the client’s platelet
count is low or if the client has been taking a medication (e.g., aspirin) that
alters platelet function. After the marrow sample is obtained, pressure is
applied to the site for several minutes. The site is then covered with a sterile
dressing.
QUESTION 21: The physician orders a transfusion with packed red blood cells (RBCs) for a
client hospitalized with severe iron deficiency anemia. When blood is
administered, what is the most important action the nurse can take to
prevent a transfusion reaction?
Correct Response: Verify the client's identity according to hospital policy
Explanation: Acute hemolytic transfusion reactions are preventable. Improper

identification is responsible for the majority of hemolytic transfusion
reactions. Meticulous attention to detail in labeling blood samples and blood
components and accurately identifying the recipient cannot be
overemphasized. It is the nurse’s responsibility to ensure that the correct

blood component is transfused to the correct client.
QUESTION 22: One hour after a transfusion of packed red blood cells (RBCs) is started, a
client develops redness on the trunk and reports itching. The nurse stops the
RBC infusion and administers diphenhydramine 25 mg po, as ordered. Thirty
minutes later, the redness and itching are gone. What action should the nurse
take next?
Correct Response: Resume the transfusion
Explanation: Some clients develop urticaria (hives) or generalized itching during a

transfusion. The cause of these reactions is thought to be a sensitivity
reaction to a plasma protein within the blood component being transfused.
Symptoms of an allergic reaction are urticaria, itching, and flushing. The
reactions are usually mild and respond to antihistamines. If the symptoms
resolve after administration of an antihistamine (e.g., diphenhydramine), the
transfusion may be resumed.
QUESTION 23: A client with a history of congestive heart failure has an order to receive
1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00
pm, by what time must the infusion be completed?
Correct Response: 4:00 pm
Explanation: When packed red blood cells (PRBCs) or whole blood is transfused, the blood
should be administered within a 4-hour period because warm room
temperatures promote bacterial growth.
QUESTION 24: One hour after the completion of a fresh frozen plasma transfusion, a client
reports shortness of breath and is very anxious. The client’s vital signs are BP
98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs
reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based
on the symptoms, the nurse suspects the client is experiencing which
problem?
Correct Response: Transfusion-related acute lung injury
Explanation: Transfusion-related acute lung injury (TRALI) is a potentially fatal,

idiosyncratic reaction that is defined as the development of acute lung injury
within 6 hours after a blood transfusion. It is more likely to occur when
plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of
transfusion, often within 2 hours). Signs and symptoms include acute
shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%;
pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio

less than 300), hypotension, fever, and eventual pulmonary edema.
QUESTION 25: A client who has idiopathic thrombocytopenia purpura (ITP) has a critically
low platelet count. Which nursing intervention will be included in the care
plan for this client?
Correct Response: Administer eltrombopag
Explanation: Thrombopoietin (TPO) is a cytokine that is necessary for the proliferation of

megakaryocytes and subsequent platelet formation. Nonimmunogenic second-
generation thrombopoietic growth factors (romiplastin and eltrombopag)
were recently approved for the treatment of idiopathic thrombocytopenia
purpura.
QUESTION 26: A nurse is teaching a client with a vitamin B12 deficiency about appropriate
food choices to increase the amount of B12 ingested with each meal. The
nurse knows the teaching is effective based on which statement by the client?
Correct Response: “I will eat a meat source such as chicken or pork with each meal.”
Explanation: Vitamin B12 is found only in foods of animal origin.
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Answer Key
QUESTION 1: Which medication is the antidote to warfarin?
Correct Response: Vitamin K
Explanation: The antidote for warfarin is vitamin K. Protamine sulfate is the antidote for
heparin. Aspirin and clopidogrel are both antiplatelet medications.
QUESTION 2: When assessing a client with a disorder of the hematopoietic or the lymphatic
system, which assessment is most essential?
Correct Response: Health history, such as bleeding, fatigue, or fainting
Explanation: When assessing a client with a disorder of the hematopoietic or the lymphatic
system, it is essential to assess the client's health history. An assessment of
drug history is essential because some antibiotics and cancer drugs contribute
to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to
bleeding and interfere with clot formation. Because industrial materials,
environmental toxins, and household products may affect blood-forming
organs, the nurse needs to explore exposure to these agents. Menstrual
history, age, gender, and lifestyle assessments, such as exercise routines and
habits, do not directly affect the hematopoietic or lymphatic system.
QUESTION 3: Which is a symptom of Cooley anemia?
Correct Response: Bronzing of the skin
Explanation: Clients with Cooley anemia exhibit symptoms of severe anemia and a bronzing
of the skin, which is caused by hemolysis of erythrocytes. Dyspnea, stomatitis
(inflammation of the mouth), and glossitis (inflammation of the tongue) are
symptoms of pernicious anemia.
QUESTION 4: For a client diagnosed with pernicious anemia, the nurse emphasizes the
importance of lifelong administration of
Explanation: For a client with pernicious anemia, the nurse emphasizes the importance of
lifelong administration of vitamin B12. The nurse teaches the client or a
family member the proper method to administer vitamin B12 injections.
Administration of vitamin A, folic acid, or vitamin C is not recommended for
this condition.
QUESTION 5: Which nursing intervention should be incorporated into the plan of care to

manage the delayed clotting process in a client with leukemia?
Correct Response: Apply prolonged pressure to needle sites or other sources of external bleeding
Explanation: For a client with leukemia, the nurse should apply prolonged pressure to
needle sites or other sources of external bleeding. Reduced platelet
production results in a delayed clotting process and increases the potential
for hemorrhage. Implementing neutropenic precautions and eliminating direct
contact with others are interventions to address the risk for infection.
QUESTION 6: Which term refers to an abnormal decrease in white blood cells, red blood
cells, and platelets?
Correct Response: Pancytopenia
Explanation: Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and

platelets. The condition may be congenital or acquired. Anemia refers to
decreased red cell mass. Leukopenia refers to a less-than-normal amount of
WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet
count.
QUESTION 7: Which term refers to a form of white blood cell involved in immune response?
Correct Response: Lymphocyte
Explanation: Both B and T lymphocytes respond to exposure to antigens. Granulocytes

include basophils, neutrophils, and eosinophils. A spherocyte is a red blood
cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.
QUESTION 8: Which type of hemolytic anemia is categorized as inherited disorder?
Correct Response: Sickle cell anemia
Explanation: Glucose 6-phosphate dehydrogenase deficiency is an inherited abnormality

resulting in hemolytic anemia. Autoimmune hemolytic anemia is an acquired
anemia. Cold agglutinin disease is an acquired anemia. Hypersplenism results
in an acquired hemolytic anemia.
QUESTION 9: Which cell of hematopoiesis is responsible for the production of red blood
cells (RBCs) and platelets?
Correct Response: Myeloid stem cell
Explanation: Myeloid stem cells are responsible not only for all nonlymphoid white blood
cells (WBC) but also for the production of red blood cells and platelets.
Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC
that becomes a macrophage when is leaves the circulation and moves into
body tissues. A neutrophil is a fully mature WBC capable of phagocytosis.
white blood cells (WBCs). Mast cells are cells found in connective tissue
involved in defense of the body and coagulation. Monocytes are large WBCs
that become macrophages when they leave the circulation and move into
body tissues.
QUESTION 11: The most common cause of iron deficiency anemia in men and
postmenopausal women is
Explanation: The most common cause of iron deficiency anemia in men and
postmenopausal women is bleeding from ulcers, gastritis, inflammatory bowel
disease or gastrointestinal (GI) tumors. Menorrhagia is the most common
cause in premenopausal women. Iron malabsorption is another cause, which is
seen in clients with celiac disease. Clients with chronic alcoholism often have
chronic blood loss from the GI tract.
QUESTION 12: Which type of sickle crisis occurs as a result of infection with the human
parvovirus?
Correct Response: Aplastic crisis
Explanation: Aplastic crisis results from infection with the human parvovirus. Sequestration
crisis results when other organs pool the sickled cells. Sickle cell crisis results
from tissue hypoxia and necrosis due to inadequate blood flow to a specific
region of tissue or organ. Acute chest syndrome is manifested by a rapidly
decreasing hemoglobin concentration, tachycardia, fever, and bilateral
infiltrates seen on chest x-ray.
QUESTION 13: A client with sickle cell anemia has a
Correct Response: low hematocrit.
Explanation: A client with sickle cell anemia has a low hematocrit and sickled cells on the
smear. A client with sickle cell trait usually has a normal hemoglobin level, a
normal hematocrit, and a normal blood smear.
QUESTION 14: The nurse should advise a client with iron deficiency anema to take which
action in order to prevent staining of the teeth?
Correct Response: Dilute liquid preparations of iron with juice and drink with a straw
Explanation: For a client with iron deficiency anemia who is taking an oral iron
supplement, the nurse instructs the client to dilute liquid preparations of iron
with another liquid, such as juice, and drink with a straw to avoid staining the
teeth. The nurse advises the client to take iron with or immediately after
meals to avoid gastric distress. The client is advised to avoid taking iron
simultaneously with an antacid, as the antacid will interfere with iron
absorption.
QUESTION 15: Which medication is the antidote to warfarin?
Correct Response: Vitamin K
Explanation: The antidote for warfarin is vitamin K. Protamine sulfate is the antidote for
heparin. Aspirin and clopidogrel are both antiplatelet medications.
QUESTION 16: When assessing a client with anemia, which assessment is essential?
Correct Response: Health history, including menstrual history in women
Explanation: When assessing a client with anemia, it is essential to assess the cliient's
health history. Women should be questioned about their menstrual periods
(e.g., excessive menstrual flow, other vaginal bleeding) and the use of iron
supplements during pregnancy.
QUESTION 17: A client with disseminated intravascular coagulation (DIC) has a critically low
fibrinogen level and is beginning to hemorrhage. To increase the amount of
fibrinogen in the body, the nurse anticipates administering which blood
product?
Correct Response: Cryoprecipitate
Explanation: Cryoprecipitate is given to replace fibrinogen and factors V and VII; fresh-
frozen plasma is administered to replace other coagulation factors.
QUESTION 18: A client is brought to the ED reporting fatigue, large amounts of bruising on

the extremities, and abdominal pain localized in the left upper quadrant. A
health history reveals the xlient has been treated for a sore throat three
times in the past 2 months. Laboratory tests indicate severe anemia,
significant neutropenia, and thrombocytopenia. Based on the symptoms, what
could be the client's diagnosis?
Correct Response: Aplastic anemia
Explanation: Aplastic anemia can be congenital or acquired, but most cases are idiopathic.
It can be triggered by infection. The manifestations of aplastic anemia are
symptoms of anemia, purpura (bruising), retinal hemorrhages, significant
neutropenia, and thrombocytopenia. Other lymphadenopathies and
splenomegaly sometimes occur.
QUESTION 19: Which is a symptom of hemochromatosis?
Correct Response: Bronzing of the skin
Explanation: Clients with hemochromatosis exhibit symptoms of weakness, lethargy,

arthralgia, weight loss, and loss of libido early in the illness trajectory. The
skin may appear hyperpigmented from melanin deposits or appear bronze in
color.
QUESTION 20: Which nursing intervention should be incorporated into the plan of care to
manage the delayed clotting process due to thrombocytopenia in a client with
leukemia?
Correct Response:
Applying prolonged pressure to needle sites or other sources of external

bleeding
Explanation: The interventions for a client with thrombocytopenia are the same as those
for a client with cancer who is at risk for bleeding. For a client with
leukemia, the nurse should apply prolonged pressure to needle sites or other
sources of external bleeding. Reduced platelet production results in a delayed
clotting process and increases the potential for hemorrhage. Implementing
neutropenic precautions and eliminating direct contact with others are
interventions to address the risk for infection.
QUESTION 21: For a client with Hodgkin disease who has developed neutropenia, what is the
most appropriate nursing intervention to include in the care plan?
Correct Response: Monitoring temperature every 4 hours
Explanation: For a client with neutropenia, monitoring temperature every 4 hours is

essential. If the client develops a fever, the client is considered to have an
infection and is usually admitted to the hospital. Cultures of blood, urine, and
sputum, as well as a chest x-ray, are obtained.
QUESTION 22: During the review of morning laboratory values for a client reporting severe
fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron
deficiency anemia based on which finding?
Correct Response: Low ferritin level concentration
Explanation: The most consistent indicator of iron deficiency anemia is a low ferritin level,
which reflects low iron stores. As the anemia progresses, the MCV, which
measures the size of the erythrocytes, also decreases. Hematocrit and RBC
levels are also low in relation to the hemoglobin concentration.
QUESTION 23: When teaching a client with iron deficiency anemia about appropriate food
choices, the nurse encourages the client to increase the dietary intake of
which foods?
Correct Response: Beans, dried fruits, and leafy, green vegetables
Explanation: Food sources high in iron include organ meats (e.g., beef or calf liver, chicken
liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and green
vegetables, raisins, and molasses. Taking iron-rich foods with a source of
vitamin C (e.g., orange juice) enhances the absorption of iron.
QUESTION 24: After teaching a client about taking daily oral iron preparations for a
moderate iron deficiency anemia, which statement by the client indicates to
the nurse that additional instruction is needed?
Correct Response: “I will call the doctor if my stools turn black.”
Explanation: Iron replacement therapy may change the color of stool, usually to dark green
or black. Iron is best absorbed on an empty stomach, so the client is
instructed to take the supplement an hour before meals. Many clients have
difficulty tolerating iron supplements because of gastrointestinal (GI) side
effects (primarily constipation). Limit GI side effects by adding a stool
softener or increasing dietary fiber and fluids. Taking iron-rich foods with a
source of vitamin C (e.g., orange juice) enhances the absorption of iron.
QUESTION 25: A client was admitted to the hospital with the following laboratory values:
hemoglobin 5 g/dL, leukocyte count 2000/mm3, and a platelet count of
48,000/mm3; abnormally shaped erythrocytes and hypersegmented
neutrophils were seen. The platelets appear abnormally large. A bone marrow
biopsy was competed and revealed hyperplasia. Based on this information,
the nurse determines that client most likely has which diagnosis?
Correct Response: Folic acid deficiency
Explanation: Anemia caused by a deficiency of folic acid cause bone marrow and
peripheral blood changes. The erythrocytes that are produced are abnormally
large and are called megaloblastic red cells. Other cells derived from the
myeloid stem cell are also abnormal. A bone marrow analysis reveals
hyperplasia (abnormal increase in the number of cells). Pancytopenia (a
decrease in all myeloid stem cell–derived cells) can develop. In advanced
stages of disease, the hemoglobin value may be as low as 4–5 g/dL, the
leukocyte count 2,000–3,000/mm3, and the platelet count less than
50,000/mm3. Cells that are released into the circulation are often abnormally
shaped. The neutrophils are hypersegmented. The platelets may be
abnormally large. The erythrocytes are abnormally shaped.
white blood cells (WBCs). Mast cells are cells found in connective tissue
involved in defense of the body and coagulation. Monocytes are large WBCs
that become macrophages when they leave the circulation and move into
body tissues.
QUESTION 27: A nursing instructor is evaluating a student caring for a neutropenic client.
The instructor concludes that the nursing student demonstrates accurate
knowledge of neutropenia based on which intervention?
Correct Response: Monitoring the client’s temperature and reviewing the client’s complete blood
count (CBC) with differential
Explanation: Clients with neutropenia often do not exhibit classic signs of infection. Fever
is the most common indicator of infection, yet it is not always present. No
definite symptoms of neutropenia appear until the client develops an
infection. A routine CBC with differential can reveal neutropenia before the
onset of infection.
QUESTION 28: A client with severe anemia reports symptoms of tachycardia, palpitations,

exertional dyspnea, cool extremities, and dizziness with ambulation.
Laboratory test results reveal low hemoglobin and hematocrit levels. Based
on the assessment data, which nursing diagnoses is most appropriate for this
client?
Correct Response: Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
Explanation: The symptoms indicate impaired tissue perfusion due to a decrease in the
oxygen-carrying capacity of the blood. Cardiac status should be carefully
assessed. When the hemoglobin level is low, the heart attempts to
compensate by pumping faster and harder in an effort to deliver more blood
to hypoxic tissue. This increased cardiac workload can result in such
symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and
exertional dyspnea. Heart failure may eventually develop, as evidenced by an
enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral
edema.
QUESTION 29: The most common cause of iron deficiency anemia in men and
postmenopausal women is
Explanation: The most common cause of iron deficiency anemia in men and
postmenopausal women is bleeding from ulcers, gastritis, inflammatory bowel
disease, or gastrointestinal (GI) tumors. Menorrhagia is the most common
cause in premenopausal women. Iron malabsorption is another cause, which is
seen in clients with celiac disease. Clients with chronic alcoholism often have
chronic blood loss from the GI tract.
QUESTION 30: The nurse should advise a client with iron deficiency anemia to take which
action in order to prevent staining of the teeth?
Correct Response: Use a straw or place a spoon at the back of the mouth to take the liquid
supplement.
Explanation: For a client with iron deficiency anemia who is taking an oral iron
supplement, the nurse instructs the client to use a straw or place a spoon at
the back of the mouth to take the liquid supplement to avoid staining the
teeth. The nurse advises the client to take iron with or immediately after
meals to avoid gastric distress. The client is advised to avoid having iron
simultaneously with an antacid, as the antacid will interferee with iron
absorption.
QUESTION 31: A client’s family member asks the nurse why disseminated intravascular
coagulation (DIC) occurs. Which statement by the nurse correctly explains the
cause of DIC?
Correct Response: "DIC is caused by abnormal activation of the clotting pathway, causing
excessive amounts of tiny clots to form inside organs."
Explanation: The inflammatory response initiates the process of inflammation and

coagulation. The natural anticoagulant pathways within the body are
simultaneously impaired, and the fibrinolytic system is suppressed, allowing a
massive amount of tiny clots forms in the microcirculation. As the platelets
and clotting factors form microthrombi, coagulation fails. Thus, the
paradoxical result of excessive clotting is bleeding. Decline in organ function
is usually a result of excessive clot formation (with resultant ischemia to all
or part of the organ).
QUESTION 32: A client with sickle cell crisis is admitted to the hospital in severe pain. While
caring for the client during the crisis, which is the priority nursing
intervention?
Correct Response: Administering and evaluating the effectiveness of opioid analgesics
Explanation: The use of medication to relieve acute pain is important. When opioid
analgesic agents are used, morphine is the medication of choice for acute
pain. Client-controlled analgesia is frequently used in the acute care setting.
QUESTION 33: When a nurse is planning discharge teaching for a client admitted with sickle
cell crisis, which information should the nurse include in the teaching?
Correct Response: Receive pneumococcal and annual influenza vaccinations
Explanation: Clients with sickle cell anemia must treat infections promptly with
appropriate antibiotics; infections, particularly pneumococcal infections, can
be serious. These clients should receive pneumococcal and annual influenza
vaccinations.
QUESTION 34: A client admitted to the hospital in preparation for a splenectomy to treat
autoimmune hemolytic anemia asks the nurse about the benefits of
splenectomy. Which statement best explains the expected effect of
splenectomy?
Correct Response: It will remove the major site of red blood cell (RBC) destruction.
Explanation: For clients with autoimmune hemolytic anemia, if corticosteroids do not

produce remission, a splenectomy (i.e., removal of the spleen) may be
performed because it removes the major site of RBC destruction.
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Answer Key
QUESTION 1: Which type of immunity becomes active as a result of infection by a specific

microorganism?
Correct Response: Naturally acquired active immunity
Explanation: Naturally acquired active immunity occurs as a result of an infection by a

specific microorganism. Artificially acquired active immunity results from the
administration of a killed or weakened microorganism or toxoid. Passive
immunity develops when ready-made antibodies are given to a susceptible
individual.
QUESTION 2: A 38-year-old client has begun to suffer from rheumatoid arthritis and is being
assessed for disorders of the immune system. The client works as an aide at a
facility that cares for children infected with AIDS. Which is the most
important factor related to the client's assessment?
Correct Response: Use of other drugs
Explanation: The nurse needs to review the client's drug history. These data will help her
to assess the client's susceptibility to illness because certain past illnesses and
drug use, such as corticosteroids, suppress the inflammatory and immune
responses. The client's age, home environment, and diet do not have any
major implications during assessment because they do not indicate the
client's susceptibility to illness.
QUESTION 3: Which adverse effect should the nurse closely monitor in a client who takes
immunosuppressive drugs?
Correct Response: Respiratory or urinary system infections
Explanation: When taking drugs to suppress the immune system, the client is vulnerable to
an increased risk of infection, especially in the respiratory or urinary systems.
Depression, memory impairment, and coma are dose-related effects of
cytokines, which are biologic response modifiers. Heart failure, infusion
reactions, and life-threatening infections are possible adverse effects of
taking infliximab, which minimizes inflammation. In addition, cytokines and

infliximab are not immunosuppressive drugs. Moreover, immunosuppressive
drugs are not known to cause rheumatoid arthritis.
QUESTION 4: A client undergoing a skin test has been intradermally injected with a
disease-specific antigen on the inner forearm. The client becomes anxious
because the area begins to swell. Which technique may be used to decrease
anxiety in this client?
Correct Response: Assure the client that this is a normal reaction
Explanation: The nurse should assure the client that this is a normal reaction. When
disease-specific antigens are injected, the injection area swells as a result of
the client developing antibodies against the antigen that is introduced. The
nurse should also keep in mind that the client is not necessarily actively
infectious if the test result is positive. Rubbing the area gently or even
applying ice packs may only aggravate the swelling. The swollen area should
be left open to heal by itself. The nurse should await the physician's
instructions before advising the client to use any prescribed analgesics.
QUESTION 5: Proteins formed when cells are exposed to viral or foreign agents that are
capable of activating other components of the immune system are referred to
as
Correct Response: interferons.
Explanation: Interferons are biologic response modifiers with nonspecific viricidal proteins.
Antibodies are protein substances developed by the body in response to and
that interact with a specific foreign substance. Antigens are substances that
induce formation of antibodies. Complement refers to a series of enzymatic
proteins in the serum that, when activated, destroy bacteria and other cells.
QUESTION 6: Which is an action of cytotoxic T cells?
Correct Response: Lyse cells infected with virus
Explanation: Cytotoxic T cells play a role in graft rejection. B cells are lymphocytes
important in producing circulating antibodies. Suppressor T cells are
lymphocytes that decrease B-cell activity to a level at which the immune
system is compatible with life. Helper T cells are lymphocytes that attack
antigens directly.
QUESTION 7: During which stage of the immune response does the circulating lymphocytes
containing the antigenic message return to the nearest lymph node?
Correct Response: Proliferation
Explanation: During the proliferation phase, the circulating lymphocytes containing the
antigenic message return to the nearest lymph node. Once in the node, the
sensitized lymphocytes stimulate some of the resident dormant T and B
lymphocytes to enlarge, divide, and proliferate. In the recognition stage, the
immune system distinguishes an invader as foreign, or non-self. In the
response stage, the changed lymphocytes function either in a humoral or
cellular fashion. In the effector stage, either the antibody of the humoral
response or the cytotoxic T cell of the cellular response reaches and couples
with the antigen on the surface of the foreign invader.
QUESTION 8: In which response do T lymphocytes have a role?
Correct Response: Transplant rejection
Explanation: Most immune responses to antigens involve both humoral and cellular
responses, although one usually predominates. For example, during transplant
rejection, the cellular response involving T cells predominates, whereas in
bacterial pneumonias and sepsis, the humoral response involving B cells plays
the dominant protective role. Transplant rejection and graft-versus-host
disease are cellular response roles of T cells. Anaphylaxis is a humoral
response role of B lymphocytes. Allergic hay fever and asthma, as well as
bacterial phagocytosis and lysis, are humoral response roles of B lymphocytes.
QUESTION 9: Which medication classification is known to inhibit prostaglandin synthesis or

release?
Correct Response: Nonsteroidal anti-inflammatory drugs (in large doses)
Explanation: Nonsteroidal anti-inflammatory drugs include aspirin and ibuprofen.

Antibiotics in large doses are known to cause bone marrow suppression.
Adrenal corticosteroids and antineoplastic agents are known to cause
immunosuppression.
QUESTION 10: Which statement accurately reflects current stem cell research?
Correct Response: The stem cell is known as a precursor cell that continually replenishes the
body's entire supply of both red and white cells.
Explanation: The stem cell is known as a precursor cell that continually replenishes the
body's entire supply of both red and white cells. Stem cells comprise only a
small portion of all types of bone marrow cells. Research conducted with
mouse models has demonstrated that once the immune system has been
destroyed experimentally, it can be completely restored with the
implantation of just a few purified stem cells. Stem cell transplantation has
been carried out in human subjects with certain types of immune
dysfunction, such as severe combined immunodeficiency. Clinical trails are
underway in clients with a variety of disorders with an autoimmune
component, including systemic lupus erythematosus, rheumatoid arthritis,
scleroderma, and multiple sclerosis.
QUESTION 11: Which stage of the immune response occurs when the differentiated
lymphocytes function in either a humoral or a cellular capacity?
Correct Response: Response stage
Explanation: In the response stage, the differentiated lymphocytes function in either a

humoral or a cellular capacity. Recognition of antigens as foreign or non-self
by the immune system is the initiating event in any immune response. In the
proliferation stage, the circulating lymphocytes containing the antigenic
message return to the nearest lymph node. In the effector stage, either the
antibody of the humoral response of the cytotoxic T cell of the cellular
response reaches and connects with the antigen on the surface of the foreign
invader.
QUESTION 12: Which response is a humoral immune response?
Correct Response: Anaphylaxis
Explanation: Anaphylaxis is an example of a humoral response. Cellular responses include

transplant rejection, intracellular infections, and delayed hypersensitivity.
QUESTION 13: In which process is the antigen-antibody molecule coated with a sticky
substance that facilitates phagocytosis?
Correct Response: Opsonization
Explanation: In the process of opsonization, the antigen-antibody molecule is coated with

a sticky substance that facilitates phagocytosis. Apoptosis is programmed cell
death that results from the digestion of DNA by endonucleases. Agglutination
is the clumping effect that occurs when an antibody acts as a cross-link
between two antigens. Immunoregulation is a complex system of checks and
balances that regulates or controls immune responses.
QUESTION 14: Which immunoglobulin assumes a major role in bloodborne and tissue

infections?
Correct Response: IgG
Explanation: IgG assumes a major role in bloodborne and tissue infections. IgA protects
against respiratory, gastrointestinal, and genitourinary infections. IgM appears
as the first immunoglobulin produced in response to bacterial and viral
infections. IgD possibly influences B-lymphocyte differentiation.
QUESTION 15: Which type of cell is capable of directly killing invading organisms and
producing cytokines?
Correct Response: Natural killer cells
Explanation: Natural killer cells defend against microorganisms and some types of
malignant cells. Null lymphocytes also combat organisms, but they destroy
antigens already coated with antibody. Memory cells are responsible for
recognizing antigens from previous exposure and mounting an immune
response. Cytotoxic T cells attack an antigen directly by altering the cell
membrane and causing cell lysis and by releasing cytolytic enzymes and
cytokines.
QUESTION 16: Which condition is associated with impaired immunity relating to the aging
client?
Correct Response: Renal function decreases
Explanation: Decreased renal circulation, filtration, absorption, and excretion contribute

to the risk for urinary tract infections. Antibody production decreases, the
skin becomes thinner, and the incidence of autoimmune disease increases
with age.
QUESTION 17: Chronic illnesses may contribute to immune system impairment in various
ways. Renal failure is associated with
Correct Response: deficiency in circulating lymphocytes.
Explanation: Renal failure is associated with a deficiency in circulating lymphocytes.

Diabetes mellitus is associated with increased incidence of infection.
Chemotherapy causes decreased bone marrow function. Leukemia is
associated with altered production of white blood cells.
QUESTION 18: Ibuprofen affects the immune system by causing
Correct Response: neutropenia.
Explanation: Ibuprofen causes leukopenia and neutropenia. Phenylbutazone causes

pancytopenia. Cefuroxime sodium causes thrombocytopenia and hemolytic
anemia.
QUESTION 19: Which assessment should be completed if immune dysfunction is suspected in

the neurosensory system?
Correct Response: Ataxia
Explanation: Ataxia should be assessed when immune dysfunction in the neurosensory

system is suspected. Hematuria, discharge, and frequency of and burning
upon urination are associated with the genitourinary system.
QUESTION 20: A 38-year-old client has been diagnosed with rheumatoid arthritis, an
autoimmune disease. During the health history assessment. the nurse learns
that the client works as an aide at a facility that cares for children infected
with AIDS, does moderate cardiovascular exercises every other day, takes no
medication, has no allergies, and eats mainly a vegetarian diet with fish and
chicken one to two times each week. Which factor is the most important
consideration in determining the status of the client’s immune system?
Correct Response: Gender
Explanation: The immune system functions of men and women differ. For example, many
autoimmune diseases have a higher incidence in females than in males, a
phenomenon believed to be correlated with sex hormones. Autoimmune
diseases tend to be more common in women because estrogen tends to
enhance immunity. Androgen, on the other hand, tends to be
immunosuppressive. Autoimmune diseases are a leading cause of death by
disease in females of reproductive age.
QUESTION 21: A nurse is caring for a client undergoing evaluation for possible immune
system disorders. Which intervention will best help support the client
throughout the diagnostic process?
Correct Response: Educate the client about the diagnostic procedures and answer their
questions about the possible diagnosis
Explanation: It is the nurse’s role to counsel, educate, and support clients throughout the
diagnostic process. Many clients may be extremely anxious about the results
of diagnostic tests and the possible implications of those results for their
employment, insurance, and personal relationships. This is an ideal time for
the nurse to provide counseling and education.
QUESTION 22: A 25-year-old client receives a knife wound to the leg in a hunting accident.
Which type of immunity was compromised?
Correct Response: Natural immunity
Explanation: Natural immunity, which is nonspecific, provides a broad spectrum of defense

against and resistance to infection. It is considered the first line of host
defense following antigen exposure, because it protects the host without
remembering prior contact with an infectious agent.
QUESTION 23: A 6-year-old client is diagnosed with a viral infection of the respiratory
system. Which will most likely be trying to fight the antigen?
Correct Response: Interferons
Explanation: Interferon, one type of biologic response modifier, is a nonspecific viricidal

protein that is naturally produced by the body and is capable of activating
other components of the immune system. Interferons have antiviral and
antitumor properties. In addition to responding to viral infection, interferons
are produced by T lymphocytes, B lymphocytes, and macrophages in response
to antigens. They are thought to modify the immune response by suppressing
antibody production and cellular immunity.
QUESTION 24: An experiment is designed to determine specific cell types involved in cell-
mediated immune response. The experimenter is interested in finding cells
that attack the antigen directly by altering the cell membrane and causing
cell lysis. Which cells should be isolated?
Correct Response: Cytotoxic T cells
Explanation: Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell
membrane and causing cell lysis (disintegration) and by releasing cytolytic
enzymes and cytokines. Lymphokines can recruit, activate, and regulate other
lymphocytes and white blood cells. These cells then assist in destroying the
invading organism.
QUESTION 25: Which medication classification is known to inhibit prostaglandin synthesis or

release?

Correct Response: Nonsteroidal anti-inflammatory drugs in large doses
Explanation: Nonsteroidal anti-inflammatory drugs (NSAIDs), in large doses, inhibit

prostaglandin synthesis or release. NSAIDs include aspirin and ibuprofen.
Antibiotics in large doses are known to cause bone marrow suppression.
Adrenal corticosteroids and antineoplastic agents are known to cause
immunosuppression.
QUESTION 26: A nurse is explaining treatment options to a client diagnosed with an immune
dysfunction. Which statement by the client accurately reflects the teaching
about current stem cell research?
Correct Response: “Stem cell transplantation has been carried out in humans with certain types
of immune dysfunction, and clinical trials using stem cells are underway in
clients with a variety of disorders with an autoimmune component.”
Explanation: Research has shown that stem cells can restore an immune system that has
been destroyed (Ko, 2012). Stem cell transplantation has been carried out in
humans with certain types of immune dysfunction, such as severe combined
immunodeficiency; clinical trials using stem cells are underway in clients with
a variety of disorders having an autoimmune component, including systemic
lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple
sclerosis. Research with embryonic stem cells has enabled investigators to
make substantial gains in developmental biology, gene therapy, therapeutic
tissue engineering, and the treatment of a variety of diseases (Ko, 2012).
However, along with these remarkable opportunities, many ethical challenges
arise, which are largely based on concerns about safety, efficacy, resource
allocation, and human cloning.
QUESTION 27: Which type of cell is capable of recognizing and killing infected or stressed
cells and producing cytokines?
Correct Response: Natural killer cells
Explanation: Natural killer cells are a class of lymphocytes that recognize infected and
stressed cells and respond by killing these cells and by secreting macrophage-
activating cytokine. Natural killer cells defend against microorganisms and
some types of malignant cells.
QUESTION 28: Which condition is associated with impaired immunity relating to the aging
client?
Correct Response: Breakdown and thinning of the skin
Explanation: The aging process stimulates changes in the immune system. Age-related
changes in many body systems also contribute to impaired immunity. Changes
such as poor circulation, as well as the breakdown of natural mechanical
barriers such as the skin, place the aging immune system at even greater
disadvantage against infection. As the immune system undergoes age-
associated alterations, its response to infections progressively deteriorates.
Humoral immunity declines and the number of inflammatory cytokines
increase with age.
QUESTION 29: A nurse is teaching a client about the side effects of ibuprofen. The client’s
learning is determined to be effective based on which statement by the
patient describing the drug's effect on the immune system?
Correct Response: “Ibuprofen can cause neutropenia, which can increase my risk of infection.”
Explanation: Ibuprofen causes leukopenia and neutropenia.
QUESTION 30: A client comes into the emergency department reporting difficulty walking
and loss of muscle control in the arms. Once the nurse begins the physical
examination, which assessment should be completed if an immune
dysfunction in the neurosensory system is suspected?
Correct Response: Assess for ataxia using the finger-to-nose test and heel-to-shin test
Explanation: Ataxia should be assessed when suspecting immune dysfunction in the

neurosensory system.
QUESTION 31: A 20-year-old client cut a hand while replacing a window. While reviewing the
complete blood count (CBC) with differential, the nurse would expect which
cell type to be elevated first in an attempt to prevent infection in the client’s
hand?
Correct Response: Neutrophils
Explanation: Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to

arrive at the site where inflammation occurs. Eosinophils and basophils, other
types of granulocytes, increase in number during allergic reactions and stress
responses.
QUESTION 32: A 34-year-old client is diagnosed with chronic hepatitis C. Testing reveals that
the client is a candidate for treatment. The nurse anticipates that which
therapy could be used to treat the client's condition?

Correct Response: Interferon
Explanation: Interferons are used to treat immune-related disorders (e.g., multiple

sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis).
QUESTION 33: At 39 weeks’ gestation, a pregnant client visits the physician for a scheduled
prenatal checkup. The physician determines that the fetus has developed an
infection in utero and sends the client for an emergency cesarean delivery.
The client is very concerned about the health of her unborn child. Based on
knowledge of the immune system, the delivery room nurse explains about
which immunoglobulin that will be increased in the fetus at the time of birth
and will be actively fighting the infection?
Correct Response: IgG
Explanation: IgG composes 75% of total immunoglobulin. It appears in serum and tissues,
assumes a major role in bloodborne and tissue infections, and crosses the
placenta.
QUESTION 34: During a 12-month well-baby visit, a mother reports that the baby has been
breastfed since birth and has never been ill. The mother is trying to convince
her sister, who is currently pregnant, to breastfeed also and asks the nurse
about the benefits of breastfeeding. The nurse explains the immune benefits
of breastfeeding and provides the mother with pamphlets. The nurse
determines the mother understands the teaching based on which statement?
Correct Response: “Breastfeeding is beneficial because the dominant antibody IgA in breast milk
acts by functioning as an antigen receptor in the mucosal membranes.”
Explanation: IgA composes 15% of total immunoglobulin. It appears in body fluids (blood,
saliva, tears, breast milk, and pulmonary, gastrointestinal, prostatic, and
vaginal secretions). It protects against respiratory, gastrointestinal, and
genitourinary infections and passes to the neonate in breast milk for
protection.
QUESTION 35: During an annual examination, an older client tells the nurse, “I don’t
understand why I need to have so many cancer screening tests now. I feel just
fine!” Based on knowledge of neoplastic disease and the aging immune
system, what teaching should the nurse include in the client’s plan of care?
Correct Response:
Tumor cells may possess special blocking factors that coat tumor cells and
prevent their destruction by killer T lymphocytes; therefore the body may not
recognize the tumor as foreign and fail to destroy the malignant cells.
Routine screening increases the chance of finding and treating cancer early.
Nutritional intake to support a competent immune response plays an
important role in reducing the incidence of cancer. A healthy diet including
protein, vitamins, minerals, and some fats can alter the risk of cancer
development.
The increase in occurrence of autoimmune diseases with aging strongly
suggests a predisposition toward various types of cancer due to the body’s
inability to differentiate between self and nonself. Routine screening
increases the chance of finding and treating cancer early.
Explanation: Large tumors can release antigens into the blood, and these antigens combine
with circulating antibodies and prevent them from attacking the tumor cells.
Furthermore, tumor cells may possess special blocking factors that coat
tumor cells and prevent their destruction by killer T lymphocytes. During the
early development of tumors, the body may fail to recognize the tumor
antigens as foreign and subsequently fail to initiate destruction of the
malignant cells. The incidence of autoimmune diseases also increases with
age, possibly from a decreased ability of antibodies to differentiate between
self and nonself. Failure of the surveillance system to recognize mutant or
abnormal cells also may be responsible, in part, for the high incidence of
cancer associated with increasing age. Vitamin D deficiency has been
associated with increased risk of common cancers. Evidence shows that
nutrition plays a role in the development of cancer and that diet and lifestyle
can alter the risk of the development of cancer and other chronic diseases.
QUESTION 36: A nurse is developing a teaching plan for a community presentation on

smoking cessation. Based on current research regarding the effects of
cigarette smoking on the immune system, which alterations in immune
function can be attributed to smoking and should be included in the teaching
presentation? Select all that apply.
Correct Response: Decreased T-cell function

Increased white blood cell count
Increased risk of infection
Decreased natural killer cells
Explanation: Smoking causes an increased white blood cell count (indicating

inflammation), an elevated T-cell count (with decreased function), decreased
antibody production (IgG, IgA, IgM), increased IgE (allergic response), and
fewer natural killer cells (increased risk for infection) in the immune system.
Quiz Stats

Answer Key
QUESTION 1: The nurse's base knowledge of primary immunodeficiencies includes which of

the following statements? Primary immunodeficiencies
Correct Response: develop early in life after protection from maternal antibodies decreases.
Explanation: These disorders may involve one or more components of the immune system.
Primary immunodeficiencies are seen primarily in infants and young children.
Primary immunodeficiencies are rare disorders with genetic origins. Without
treatment, infants and children with these disorders seldom survive to
adulthood.
QUESTION 2: Agammaglobulinemia is also known as
Correct Response: Bruton's disease.
Explanation: Bruton's disease is a sex-linked disease that results in infants born with the
disorder suffering severe infections soon after birth. Nezelof syndrome is a
disorder involving lack of a thymus gland. Wiskott-Aldrich syndrome involves
the absence of T cells and B cells and the presence of thrombocytopenia.
CVID is another term for hypogammaglobulinemia.
QUESTION 3: When the nurse administers intravenous gamma-globulin infusion, she

recognizes that which of the following complaints, if reported by the patient,
may indicate an adverse effect of the infusion?
Correct Response: Tightness in the chest
Explanation: Flank pain, tightness in the chest, or hypotension indicates adverse effects of
gamma-globulin infusion. Nasal stuffiness is not recognized as an adverse
effect of gamma-globulin infusion. Increased thirst is not recognized as an
adverse effect of gamma-globulin infusion. Burning urination is a sign of
urinary tract infection, not an adverse effect of gamma-globulin infusion.
QUESTION 4: Ataxia is the term that refers to
Correct Response: uncoordinated muscle movement.
Explanation: Ataxia-telangiectasia is an autosomal recessive disorder affecting both T-cell

and B-cell immunity. Telangiectasia is the term that refers to vascular lesions
caused by dilated blood vessels. Receptive aphasia is an inability to
understand the spoken word. Dysphagia refers to difficulty swallowing.
QUESTION 5: A major manifestation of Wiskott-Aldrich syndrome includes which of the

following?
Correct Response: Thrombocytopenia
Explanation: Major symptoms of Wiskott-Aldrich syndrome include thrombocytopenia,

infections, and malignancies. Ataxia occurs with ataxia-telangiectasia.
Episodes of edema in various body parts occur with angioneurotic edema.
Bacterial infection occurs with hyperimmunoglobulinemia E syndrome.
QUESTION 6: Which term means a lack of one or more of the five immunoglobulins?
Correct Response: Hypogammaglobulinemia
Explanation: Hypogammaglobulinemia is a lack of one or more of the five

immunoglobulins. Agammaglobulinemia is a disorder marked by an almost
complete lack of immunoglobulins or antibodies. Panhypoglobulinemia is a
general lack of immunoglobulins in the blood. Telangiectasias are vascular
lesions caused by dilated blood vessels.
QUESTION 7: A majority of patients with CVID develop which type of anemia?
Correct Response: Pernicious
Explanation: A majority of patients with CVID develop pernicious anemia. The majority of
patients with CVID do not develop the other types of anemia.
QUESTION 8: T-cell deficiency occurs when which of the following glands fails to develop
normally during embryogenesis?
Correct Response: Thymus
Explanation: T-cell deficiency occurs when the thymus gland fails to develop normally
during embryogenesis.
QUESTION 9: Infants with DiGeorge syndrome have which type of endocrine disorder?
Correct Response: Hypoparathyroidism
Explanation: Infants born with DiGeorge syndrome have hypoparathyroidism with resultant
hypocalcemia resistant to standard therapy. The other endocrine disorders do
not occur in DiGeorge syndrome.
QUESTION 10: Which type of disorder produces recurrent and persistent infection of the soft
tissue, lungs, and other organs?
Correct Response: Primary phagocytic disorder
Explanation: Chronic granulomatous disease, a type of primary phagocytic disorder,

produces recurrent or persistent infections of the soft tissues, lungs and other
organs. The other deficiencies do not apply to recurrent and persistent
infection of the soft tissue, lungs, and other organs.
QUESTION 11: Which type of phagocytic disorder occurs when white blood cells cannot
initiate an inflammatory response to infectious organisms?
Correct Response: Hyperimmunoglobulinemia
Explanation: In hyperimmunoglobulinemia, white blood cells cannot initiate an

inflammatory response to an infectious organism. Agammaglobulinemia is a
disorder marked by an almost complete lack of immunoglobulins or
antibodies. Panhypoglobulinemia is a general lack of immunoglobulins in the
blood. Telangiectasias are vascular lesions caused by dilated blood vessels.
QUESTION 12: A treatment option for SCID includes
Correct Response: a stem cell transplant.
Explanation: Treatment options for SCID include stem cell and bone marrow
transplantation. Other treatment regimens include administration of IVIG or
thymus-derived factors and thymus gland transplantation.
QUESTION 13: Which of the following would be inaccurate information pertaining to SCID?
Correct Response: The inheritance of SCID can be autosomal dominant.
Explanation: The inheritance of SCID can be X-linked, autosomal recessive, or sporadic.

The incidence is unknown. It is one of the most common causes of primary
immunodeficiency and affect B cells and T cells.
QUESTION 14: A patient comes in to get an EIA test done because her physician suspects
AIDS. Which of the following nursing actions is essential before an EIA test is
performed?
Correct Response: Obtaining a general consent for medical care from the patient
Explanation: Separate written consent for HIV testing should not be required; general
consent for medical care should be considered sufficient to encompass
consent for HIV testing. The Western blot is performed if the results of the
EIA test are positive. A polymerase chain reaction test, which measures viral
loads, is used if diagnosis is confirmed as positive.
QUESTION 15: A patient is administered foscarnet to treat a case of CMV retinitis. Which of
the following adverse effects should the nurse closely monitor in the patient?
Correct Response: Electrolyte imbalances
Explanation: Alterations in renal function, fever, nausea, electrolyte imbalances and

diarrhea are the most common adverse effects of foscarnet and should be
closely monitored. The drug does not cause hypotension. On the other hand,
peripheral neuropathy is an adverse effect of administering drugs such as
didanosine and zalcitabine. Anemia is an adverse effect of administering
zidovudine.
QUESTION 16: Which of the following options should the nurse encourage to replace fluid
and electrolyte losses in a patient with AIDS?
Correct Response: Liquids
Explanation: The nurse should encourage patients with AIDS to have liquids to help in
replacing fluid and electrolyte losses. Gluten and sucrose may increase the
complication of malabsorption. Large doses of iron and zinc should be avoided
because they can impair immune function.
QUESTION 17: Which of the following microorganisms is known to cause retinitis in people
with HIV/AIDS?
Correct Response: Cytomegalovirus
Explanation: Cytomegalovirus is a species-specific herpes virus. Cryptococcus neoformans

is a fungus that causes an opportunistic infection in patients with HIV/AIDS.
Mycobacterium avium is an acid-fast bacillus that commonly causes a
respiratory illness. Pneumocystis carinii is an organism that is thought to be
protozoan but believed to be a fungus based on its structure.
QUESTION 18: Which blood test confirms the presence of antibodies to HIV?
Correct Response: Enzyme-linked immunoabsorbent assay (ELISA)
Explanation: ELISA, as well as Western blot assay, identifies and confirms the presence of
antibodies to HIV. The ESR is an indicator of the presence of inflammation in
the body. The p24 antigen is a blood test that measures viral core protein.
Reverse transcriptase is not a blood test. Rather, it is an enzyme that
transforms single-stranded RNA into a double-stranded DNA.
QUESTION 19: When assisting the patient to interpret a negative HIV test result, the nurse
informs the patient that the results mean that
Correct Response: his body has not produced antibodies to the AIDS virus.
Explanation: A negative test result indicates that antibodies to the AIDS virus are not
present in the blood at the time the blood sample for the test is drawn. A
negative test result should be interpreted as demonstrating that if infected,
the body has not produced antibodies (which takes from 3 weeks to 6 months
or longer). Therefore, subsequent testing of an at-risk patient must be
encouraged. The test result does not mean that the patient is immune to the
virus, nor does it mean that the patient is not infected. It just means that the
body may not have produced antibodies yet. When antibodies to the AIDS
virus are detected in the blood, the test is interpreted as positive.
QUESTION 20: Which of the following substances may be used to lubricate a condom?
Correct Response: K-Y jelly
Explanation: K-Y jelly is water-based and will provide lubrication while not damaging the
condom.The oil in skin lotion will cause the condom to break. Baby oil and
the oil in petroleum jelly will cause the condom to break.
QUESTION 21: Which stage of HIV infection is indicated when the results are more than 500
CD4+ lymphocytes/mm?
Correct Response: CDC category A: HIV asymptomatic
Explanation: More than 500 CD4+ T lymphocytes/mmindicates CDC category A: HIV

asymptomatic. The period from infection with HIV to the development of
antibodies to HIV is known as primary infection and 200 to 499 CD4+ T
lymphocytes/mm indicates CDC category B: HIV symptomatic. Less than 200
CD4+ T lymphocytes/mm3 indicates CDC category C: AIDS.
QUESTION 22: The term used to define the balance between the amount of HIV in the body
and the immune response is
Correct Response: viral set point.
Explanation: The viral set point is the balance between the amount of HIV in the body and
the immune response. During the primary infection period, the window period
occurs since a person is infected with HIV but negative on the HIV antibody
blood test. The period from infection with HIV to the development of
antibodies to HIV is known as the primary infection stage. The amount of virus
in circulation and the number of infected cells equals the rate of viral
clearance.
QUESTION 23: Which of the following statements reflects the treatment of HIV infection?
Correct Response: Treatment of HIV infection for an individual patient is based on the clinical
condition of the patient, CD4 T cell count level, and HIV RNA (viral load).
Explanation: Although specific therapies vary, treatment of HIV infection for an individual
patient is based on three factors: the clinical condition of the patient, CD4 T
cell count level, and HIV RNA (viral load). Treatment should be offered to all
patients with the primary infection (acute HIV syndrome). In general,
treatment should be offered to individuals with fewer than 350 CD4+ T
cells/mm or plasma HIV RNA levels exceeding 55,000 copies/mL (RT-PCR
assay).
QUESTION 24: When do most perinatal HIV infections occur?
Correct Response: After exposure during delivery
Explanation: Mother-to-child transmission of HIV-1 may occur in utero or through

breastfeeding, but most perinatal infections are thought to occur after
exposure during delivery.
QUESTION 25: Other than abstinence, what is the only proven method of decreasing the risk
for sexual transmission of HIV infection?
Correct Response: Consistent and correct use of condoms
Explanation: Other than abstinence, consistent and correct use of condoms is the only
method proven to decrease the risk for sexual transmission of HIV infection.
Vaginal lubricants, birth control pills, and spermicides are not proven means
of decreasing the risk for sexual transmission of HIV infection.
QUESTION 26: The balance between the amount of HIV in the body and the immune
response is the
Correct Response: viral set point.
Explanation: The balance between the amount of HIV in the body and the immune
response is the viral set point.A viral load test measures the quantity of HIV
RNA in the blood. The window period is the time from infection with HIV until
seroconversion detected on HIV antibody test. Anergy is the loss or weakening
of the body's immunity to an irritating agent or antigen.
QUESTION 27: Which diagnostic test measures HIV RNA in the plasma?
Correct Response: Viral load
Explanation: A viral load test measures the quantity of HIV RNA in the blood. Enzyme
immunoassay is a blood test that can determine the presence of antibodies to
HIV in the blood or saliva that is also referred to as an ELISA. A Western blot
assay is a blood test that identifies antibodies to HIV and is used to confirm
the results of an EIA (ELISA) test.
QUESTION 28: The lower the patient's viral load,
Correct Response: the longer the survival time.
Explanation: The lower the patient's viral load, the longer the survival time.
QUESTION 29: Which of the following is usually the most important consideration in
decisions to initiate antiretroviral therapy?
Correct Response: CD4 counts
Explanation: The most important consideration in decisions to initiate antiretroviral

therapy is CD4 counts.
QUESTION 30: Antiretroviral medications should be offered to individuals with T-cell counts
of less than
Correct Response: 350 cell/mm.
Explanation: In general, antiretroviral medications should be offered to individuals with a

T-cell count of less than 350 cell/mm or plasma HIV RNA levels exceeding
100,000 copies/mL.
QUESTION 31: Which of the following has not been implicated as a factor for noncompliance
with antiretroviral treatment?
Correct Response: Past substance abuse
Explanation: Past substance abuse has not been implicated as a factor for noncompliance
with antiretroviral treatment. Factors associated with nonadherence include
active substance abuse, depression, and lack of social support.
QUESTION 32: Diagnosis of Kaposi's sarcoma (KS) is made by which of the following?
Correct Response: Biopsy
Explanation: Diagnosis of KS is made by biopsy of the suspected lesions. Prognosis depends

on the extent of the tumor, the presence of other symptoms of HIV infection,
and the CD4+ count.
QUESTION 33: Which of the following is an early manifestation of HIV encephalopathy?
Correct Response: Headache
Explanation: An early manifestation of HIV encephalopathy is a headache. Later stages

include hyperreflexia, a vacant stare, and hallucinations.
QUESTION 34: A patient is scheduled to receive an intravenous immunoglobulin (IVIG)

infusion. He asks the nurse about the infusion’s administration and its adverse
effects. Which of the following choices should the nurse instruct this patient
to report immediately?
Correct Response: Tickle in the throat
Explanation: Continually assess the patient for adverse reactions; be especially aware of
complaints of a tickle or lump in the throat, which could be the precursor to
laryngospasm that precedes bronchoconstriction.
QUESTION 35: A nurse is teaching the parents of an infant about primary

immunodeficiencies. Which of the following statements verifies that the
parents understand the teaching?
Correct Response: “The majority of primary immunodeficiencies are diagnosed in infancy.”
Explanation: The majority of primary immunodeficiencies are diagnosed in infancy, with a

male-to-female ratio of 5 to 1.
QUESTION 36: An infant is diagnosed with agammaglobulinemia. The nurse reviews the
family history for a male relative with this disorder, which the nurse knows is
also known by which of the following names?
Correct Response: Bruton’s disease
Explanation: This syndrome is called X-linked agammaglobulinemia (Bruton’s disease).

Bruton’s disease is a sex-linked disease that results in infants born with the
disorder suffering severe infections soon after birth. Nezelof syndrome is a
disorder involving lack of a thymus gland. Wiskott-Aldrich syndrome involves
the absence of T cells and B cells and the presence of thrombocytopenia.
CVID is another term for hypogammaglobulinemia.
QUESTION 37: A nurse is assessing a patient with a primary immunodeficiency. Afterward she
documents that the patient displayed ataxia. Which of the following
statements explains the documentation?
Correct Response: The patient has uncoordinated muscle movements.
Explanation: Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder

characterized by cerebellar ataxia (loss of muscle coordination).
QUESTION 38: A patient with common variable immunodeficiency (CVID) comes to the ED
with complaints of tingling and numbness in the hands and feet, muscle
weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal
tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid
hyperplasia of the small intestine and spleen as well as gastric atrophy. Based
on these findings, what common secondary problem has this patient
developed?
Correct Response: Pernicious anemia
Explanation: More than 50% of patients with CVID develop pernicious anemia. Lymphoid
hyperplasia of the small intestine and spleen and gastric atrophy, which is
detected by biopsy of the stomach, are common findings. Gastrointestinal
malabsorption may occur.
QUESTION 39: During a third-trimester transabdominal ultrasound, cardiac anomaly and

facial abnormalities are noted on the fetus. Further testing reveals that the
thymus gland has failed to develop normally and the fetus is diagnosed with
thymic hypoplasia. Based on this diagnosis, the nurse anticipates careful
monitoring for which common manifestation during the first 24 hours of life?
Correct Response: Hypocalcemia
Explanation: The most frequent presenting sign in patients with thymic hypoplasia
(DiGeorge syndrome) is hypocalcemia that is resistant to standard therapy. It
usually occurs within the first 24 hours of life.
QUESTION 40: A nurse is reviewing treatment options with parents of an infant born with
severe combined immunodeficiency disease (SCID). The nurse recognizes that
the parents understand the teaching based on which of the following
statements?
Correct Response: “We could have our 10-year-old daughter tested, as the ideal stem cell donor
is a human leukocyte antigen (HLA)-identical sibling.”
Explanation: CDATA[Treatment options for SCID include stem cell and bone marrow
transplantation. HSCT is the definitive therapy for SCID; the best outcome is
achieved if the disease is recognized and treated early in life.sThe ideal
donor is a human leukocyte antigen (HLA)-identical sibling.
QUESTION 41: A nurse is reviewing the causes of genetic diseases with parents of an infant
born with severe combined immunodeficiency disease (SCID). Which of the
following would be inaccurate information pertaining to SCID?
Correct Response: The inheritance of SCID can be autosomal dominant.
Explanation: It is one of the most common causes of primary immunodeficiencies.

Inheritance of this disorder can be X linked, autosomal recessive, or sporadic.
The exact incidence of SCID is unknown; it is recognized as a rare disease in
most population groups, with an incidence of about 1 case in 1,000,000. This
illness occurs in all racial groups and both genders.
QUESTION 42: Which of the following adverse effects should the nurse closely monitor in a
patient who has secondary immunodeficiencies due to immunosuppressive
therapy?
Correct Response: Respiratory or urinary system infections
Explanation: Secondary immunodeficiencies occur as a result of underlying disease

processes or the treatment of these disorders, including administration of
immunosuppressive agents. Abnormalities of the immune system affect both
natural and acquired immunity. Because immunodeficiencies result in a
compromised immune system and pose a high risk for infection, careful
assessment of the patient’s immune status is essential. The nurse assesses
and monitors the patient for signs and symptoms of infection.
QUESTION 43: A patient seen in the outpatient clinic has common variable
immunodeficiency. It is important for the nurse to teach the patient about
the need for more frequent screening for which of the following
complications?
Correct Response: Malignancy
Explanation: Advances in medical treatment have meant that patients with primary
immunodeficiencies live longer, thus increasing their overall risk of
developing cancer. Non-Hodgkin lymphomas account for most cancers. The
primary immunodeficiencies known to be associated with increased incidence
of malignancy are common variable immunodeficiency, immunoglobulin A
(IgA) deficiency, and deoxyribonucleic acid (DNA) repair disorders.
QUESTION 44: Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG)
infusion, the patient complains of itching at the site and a lump in the throat.
Which is the first action the nurse should take?
Correct Response: Stop the infusion.
Explanation: Continually assess the patient for adverse reactions; be especially aware of
complaints of a tickle or lump in the throat as the precursor to laryngospasm
that precedes bronchoconstriction. Stop the infusions at the first sign of
reaction and initiate the institutional protocol to be followed in this emergent
situation.
QUESTION 45: The nurse is obtaining an assessment and health history from the parents of a
6-month-old infant with an elevated temperature. Which statement by the
parents will alert the nurse to a possible immunodeficiency disorder?
Correct Response: “This is the third infection with a high fever the baby has had in the past
month.”
Explanation: Infants with X-linked agammaglobulinemia usually become symptomatic after

the natural loss of maternally transmitted immunoglobulins, which occurs at
about 5 to 6 months of age. Symptoms of recurrent pyogenic infections
usually occur by that time.
QUESTION 46: A patient with severe combined immunodeficiency disease is receiving

immunosuppression therapy to ensure engraftment of depleted bone marrow
during transplantation procedures. What is the priority nursing care for this
patient?
Correct Response: Meticulous infection control precautions
Explanation: Nursing care must be meticulous. Appropriate infection control precautions

and thorough hand hygiene are essential. Institutional policies and procedures
related to protective care must be followed scrupulously until definitive
evidence demonstrates that precautions are unnecessary. Continual
monitoring of the patient’s condition is critical, so early signs of impending
infection may be detected and treated before they seriously compromise the
patient’s status. It also is imperative that nurses appropriately apply standard
precautions (previously known as universal precautions), which have become
one of the first-line tools for decreasing transmission of disease.
QUESTION 47: A man with chronic mucocutaneous candidiasis, an autosomal recessive

disorder, asks the nurse, “Will my children have this disease?” Which response
by the nurse is appropriate?
Correct Response: “All of your children will be carriers of the recessive gene but may not
develop the disease.”
Explanation: Chronic mucocutaneous candidiasis is a rare T-cell disorder, which is thought

to be an autosomal recessive disorder that affects both males and females. In
pedigrees, an autosomal recessive disorder is revealed by the appearance of
the phenotype in the male and female progeny of unaffected individuals.
Parents must both be heterozygotes, C/c. (Both must have a c allele in order
to contribute one to create a homozygote affected child with a cc phenotype
displaying the disease.) A child born with Cc will be phenotypically normal,
but carry the recessive trait.
QUESTION 48: The nurse is caring for a young patient who has agammaglobulinemia. The
nurse is teaching the family how to avoid infection at home. Which statement
by the family indicates that additional teaching is needed?
Correct Response: “I can take my child to the beach, as long as we play in the sand rather than
swim in the water.”
Explanation: Parents should verbalize ways to plan for regular exercise and activity that
does not pose a risk of infections. Immunocompromised patients should avoid
touching sand or soil because of the high level of bacteria and increased risk
of diseases such as toxoplasmosis.
QUESTION 49: The nurse is teaching the patient who has an immunodeficiency disorder how
to avoid infection at home. Which statement indicates that additional
teaching is needed?
Correct Response: “I will be sure to eat lots of fresh fruits and vegetables every day.”
Explanation: The patient should avoid eating raw fruits and vegetables. All foods should be
cooked thoroughly and all leftover food should be refrigerated immediately to
prevent infection.
QUESTION 50: The nurse is working with a mother whose child has just been diagnosed with
selective immunoglobulin A deficiency. The mother asks the nurse, “Does this
mean that my child is going to die?” How will the nurse respond?
Correct Response: “Your child has a mild genetic immune deficiency caused by a lack of
immunoglobulin A (IgA), a type of antibody that protects against infections of
the lining the mouth and digestive tract.”
Explanation: Selective immunoglobulin A deficiency is congenital and characterized by a

lack of immunoglobulin A, which predisposes patients to recurrent infections,
adverse reactions to blood transfusions or immunoglobulin, autoimmune
diseases, and hypothyroidism. There is no current treatment.
QUESTION 51: A patient with paroxysmal hemoglobinuria, a deficiency of complement

proteins, is complaining of headache and weakness of the right arm and leg.
Based on these symptoms, for which health complication should the nurse
assess with this patient?
Correct Response: Cerebral venous thrombosis
Explanation: Paroxysmal nocturnal hemoglobinuria is an acquired clonal stem cell disorder

resulting from a somatic mutation in the hematopoietic stem cell. Clinical
manifestations may be indolent or life threatening. The disorder is
characterized by hemoglobinuria that increases during sleep, as well as
intravascular hemolysis, cytopenia, infections, bone marrow hyperplasia, and
a high incidence of life-threatening venous thrombosis, which occurs most
commonly in the abdominal and cerebral veins.
QUESTION 52: A patient with common variable immunodeficiency disease (CVID) has an
order for an IVIG infusion. What actions should the nurse perform prior to
beginning the infusion? Select all that apply.
Correct Response: Premedicate with acetaminophen and diphenhydramine.

Assess baseline vital signs.
Assess for history of migraine headaches.
Obtain the patient’s height and weight.
Explanation: Variables affecting the risk and intensity of adverse events associated with
the administration of IVIG include patient age, underlying condition, history
of migraine, and cardiovascular and/or renal disease; dose, concentration,
and rate of infusion. The nurse must assess all of these variables before
starting the IVIG infusion: obtain height and weight before treatment to
verify accurate dosing; assess baseline vital signs before, during, and after
treatment; premedicate with acetaminophen and diphenhydramine as
prescribed 30 minutes before the start of the infusion.
QUESTION 53: Which of the following nursing actions is essential before an EIA test is
performed?
Correct Response: Obtaining a general consent for medical care from the patient
Explanation: Separate written consent for HIV testing should not be required; general
consent for medical care should be considered sufficient to encompass
consent for HIV testing. The Western blot test is performed if the results of
the EIA test are positive. A polymerase chain reaction test, which measures
viral loads, is used if diagnosis is confirmed as positive.
QUESTION 54: A patient is administered foscarnet to treat a case of cytomegalovirus (CMV)

retinitis. Which of the following adverse effects should the nurse closely
monitor in the patient?
Correct Response: Electrolyte imbalances
Explanation: Alterations in renal function, fever, nausea, electrolyte imbalances, and

diarrhea are the most common adverse effects of foscarnet and should be
closely monitored. The drug does not cause hypotension. On the other hand,
peripheral neuropathy is an adverse effect of administering drugs such as
didanosine and zalcitabine. Anemia is an adverse effect of administering
zidovudine.
QUESTION 55: What intervention is a priority when treating a patient with HIV /AIDS?
Correct Response: Assessing fluid and electrolyte balance
Explanation: Fluid and electrolyte deficits are a priority in monitoring patients with
HIV/AIDS. Assessment of fluid loss and electrolyte imbalance is essential. Skin
integrity should be monitored, but is a lower priority. Neurologic and
psychological status should also be monitored, but this is not as high a priority
as fluid and electrolyte imbalance.
QUESTION 56: Which of the following microorganisms is known to cause retinitis in people
with HIV/AIDS?
Correct Response: Cytomegalovirus
Explanation: Cytomegalovirus is a species-specific herpes virus. Cryptococcus neoformans

is a fungus that causes an opportunistic infection in patients with HIV/AIDS.
Mycobacterium avium is an acid-fast bacillus that commonly causes a
respiratory illness. Pneumocystis carinii is an organism that is thought to be
protozoan, but believed to be a fungus based on its structure.
QUESTION 57: Which blood test confirms the presence of antibodies to HIV?
Correct Response: Enzyme-linked immunosorbent assay (ELISA)
Explanation: ELISA, as well as Western blot assay, identifies and confirms the presence of
antibodies to HIV. The ESR is an indicator of the presence of inflammation in
the body. The p24 antigen is a blood test that measures viral core protein.
Reverse transcriptase is not a blood test. Rather, it is an enzyme that
transforms single-stranded RNA into a double-stranded DNA.
QUESTION 58: When assisting the patient to interpret a negative HIV test result, what does
the nurse tell the patient this result means?
Correct Response: His body has not produced antibodies to the AIDS virus.
Explanation: A negative test result indicates that antibodies to the AIDS virus are not
present in the blood at the time the blood sample for the test is drawn. A
negative test result should be interpreted as demonstrating that, if infected,

the body has not produced antibodies (which takes from 3 weeks to 6 months
or longer). Therefore, subsequent testing of an at-risk patient must be
encouraged. The test result does not mean that the patient is immune to the
virus, nor does it mean that the patient is not infected. It just means that the
body may not have produced antibodies yet. When antibodies to the AIDS
virus are detected in the blood, the test is interpreted as positive.
QUESTION 59: Which stage of HIV infection is indicated when the results are more than 500
CD4+ lymphocytes/mm?
Correct Response: Primary infection (acute HIV infection or acute HIV syndrome)
Explanation: More than 500 CD4+ T lymphocytes/mm indicates CDC stage 1.
QUESTION 60: The term used to define the balance between the amount of HIV in the body
and the immune response is which of the following?
Correct Response: Viral set point
Explanation: The viral set point is the balance between the amount of HIV in the body and
the immune response. During the primary infection period, the window period
occurs since a person is infected with HIV but negative on the HIV antibody
blood test. The period from infection with HIV to the development of
antibodies to HIV is known as the primary infection stage. The amount of virus
in circulation and the number of infected cells equals the rate of viral
clearance.
QUESTION 61: When do most perinatal HIV infections occur?
Correct Response: After exposure during delivery
Explanation: Mother-to-child transmission of HIV-1 may occur in utero or through

breastfeeding, but most perinatal infections are thought to occur after
exposure during delivery.
QUESTION 62: The nurse teaches the patient that lowering his or her viral load will have
what effect?
Correct Response: A longer survival time
Explanation: The lower the patient's viral load, the longer the survival time.
QUESTION 63: Which assessment finding is not likely to cause noncompliance with
antiretroviral treatment?
Correct Response: Past substance abuse
Explanation: Past substance abuse has not been implicated as a factor for noncompliance
with antiretroviral treatment. Factors associated with nonadherence include
active substance abuse, depression, and lack of social support.
QUESTION 64: Diagnosis of Kaposi’s sarcoma (KS) is made by which of the following?
Correct Response: Biopsy
Explanation: Diagnosis of KS is made by biopsy of the suspected lesions. Visual assessment

will not confirm a diagnosis. A CT scan will not assist in determining skin cell
changes. Skin scraping is a procedure to collect cells, not to evaluate cells.
QUESTION 65: A client taking abacavir (ABC) has developed fever and rash. What is the
priority nursing action?
Correct Response: Call the health care provider to report.
Explanation: Fever and a rash could be indicative of a hypersensitivity reaction.

Hypersensitivity reactions are also known as anaphylactic reactions and often
involve skin rashes, fever, and bronchopulmonary issues such as bronchial
constriction. The health care provider should be notified immediately and the
medication stopped. Interventions need to be taken to assure that the
patient's airway is not compromised. Administering Tylenol and
documentation and treating the rash are not the priority, and would be
completed after the patient was stabilized.
QUESTION 66: What intervention is appropriate before the patient starts on efavirenz (EFV,
Sustiva) therapy?
Correct Response: Testing for Stevens-Johnson syndrome potential
Explanation: A patient should be tested for the gene for Stevens-Johnson syndrome prior to
receiving any drugs that potentially can cause this condition. The patient
does not have to receive Benadryl or have renal function tests. There are no
particular foods that should be restricted.
QUESTION 67: A patient taking amprenavir (APV, Agenerase) complains of “getting fat.”
What is the nurse’s best action?
Correct Response: Teach the patient about medication side effects.
Explanation: The patient needs to be aware of the potential for fat redistribution.
Exercise, diet, and counseling will not change the outcome of this side effect.
QUESTION 68: A client receiving atazanavir (ATV, Reyataz) requires what priority
intervention?
Correct Response: Cardiac assessment
Explanation: This medication may cause prolongation of the PR interval and first degree AV
block. Patients with underlying conduction deficits may develop problems. A
cardiac assessment will assist in determining if the patient has underlying
problems that could be exacerbated by this drug therapy. The other
interventions are not necessary.
QUESTION 69: What test will the nurse assess to determine the patient’s response to
antiretroviral therapy?
Correct Response: Viral load
Explanation: Viral load is used to assess response to treatment of HIV infection. The other
tests are not used in this way.
QUESTION 70: The nurse is teaching the patient with HIV about therapy. What is essential
for the nurse to include in the teaching plan? Select all that apply.
Correct Response: The CD4 count is the major indicator of immune function and guides therapy.
Antiretroviral therapy targets different stages of the HIV life cycle.
Explanation: The CD4 count is the major indicator of immune function. Antiretroviral
therapy in HIV targets different stages of the HIV life cycle. Therapy does not
prevent opportunistic infections. Medication therapy is effective and most
patients respond well to therapy.
QUESTION 71: A patient receiving antiretroviral therapy is complaining of “not urinating

enough.” What is the nurse’s best action?
Correct Response: Assess BUN and creatinine.
Explanation: Adverse effects associated with antiretroviral therapy include potential

nephrotoxicity. Assessing BUN and creatinine for patients who have decreased
urination is appropriate. The other answers will not assist the nurse in
determining the patient's problem. Assessment of the problem should be
undertaken before interventions.
QUESTION 72: A patient being treated for HIV/AIDS has a decreased appetite, almost to the
point of anorexia. What is the nurse’s best action?
Correct Response: Administer megestrol acetate (Megace).
Explanation: Appetite stimulants are successfully used in patients with AIDS-related

anorexia. The anorexia is compounded by medications that cause nausea and
vomiting. The anorexia has a physiologic cause, and this must be addressed.
Bringing in favorite foods or making favorite foods may have little or no effect
on the patient's appetite; it is physiologically rather than psychologically
based.
Quiz Stats

Answer Key
QUESTION 1: Which body substance causes increased gastric secretion, dilation of

capillaries, and constriction of the bronchial smooth muscle?
Correct Response: Histamine
Explanation: When cells are damaged, histamine is released. Bradykinin is a polypeptide

that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator
that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins
are unsaturated fatty acids that have a wide assortment of biologic activities.
QUESTION 2: Which type of hypersensitivity reaction involves immune complexes forming

when antigens bind to antibodies?
Correct Response: Type III
Explanation: Type III hypersensitivity is associated with systemic lupus erythematosus,

rheumatoid arthritis, serum sickness, certain types of nephritis, and some
types of bacterial endocarditis. Type I, or anaphylactic hypersensitivity, is an
immediate reaction, beginning within minutes of exposure to an antigen. Type
II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies
a normal constituent of the body as foreign. Type IV, or delayed-type,
hypersensitivity occurs 24 to 72 hours after exposure to an allergen.
QUESTION 3: Which intervention is the single most important aspect for the client at risk
for anaphylaxis?
Correct Response: Prevention
Explanation: Clients who have experienced food, medication, idiopathic, or exercise-

induced anaphylactic reactions should always carry an emergency kit
containing epinephrine for injection to prevent the onset of the reaction upon
exposure. While helpful, there must be no lapses in desensitization therapy
because this may lead to the reappearance of an allergic reaction when the
medication is reinstituted. A medical alert bracelet will assist those rendering
aid to a client who has experienced an anaphylactic reaction.
QUESTION 4: The nurse observes diffuse swelling involving the deeper skin layers in a client
who has experienced an allergic reaction. The nurse would correctly
document this finding as
Correct Response: angioneurotic edema.
Explanation: The area of skin demonstrating angioneurotic edema may appear normal but
often has a reddish hue and does not pit. Urticaria (hives) is characterized as
edematous skin elevations that vary in size and shape, itch, and cause local
discomfort. Contact dermatitis refers to inflammation of the skin caused by
contact with an allergenic substance such as poison ivy. Pitting edema is the
result of increased interstitial fluid and associated with disorders such as
congestive heart failure.
QUESTION 5: Atopic allergic disorders are characterized by
Correct Response: a hereditary predisposition.
Explanation: Atopic allergic disorders are characterized by a hereditary predisposition and

production of a local reaction to IgE antibodies produced in response to
common environmental allergens. Atopic and nonatopic allergic disorders are
IgE-mediated allergic reactions.
QUESTION 6: The nurse teaches the client with allergies about anaphylaxis, including which
statement?
Correct Response: The most common cause of anaphylaxis is penicillin.
Explanation: The most common cause of anaphylaxis, accounting for about 75% of fatal
anaphylactic reactions in the United States, is penicillin. Although possibly
severe, anaphylactoid reactions are rarely fatal. Food items that are common
causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs,
soy, and wheat. Local reactions usually involve urticaria and angioedema at
the site of the antigen exposure. Systemic reactions occur within about 30
minutes of exposure involving cardiovascular, respiratory, gastrointestinal,
and integumentary organ systems.
QUESTION 7: Which statement describes the clinical manifestations of a delayed

hypersensitivity (type IV) allergic reaction to latex?
Correct Response: They are localized to the area of exposure, usually the back of the hands.
Explanation: Clinical manifestations of a delayed hypersensitivity reaction are localized to

the area of exposure. Clinical manifestations of an irritant contact dermatitis
can be eliminated by changing glove brands or using powder-free gloves. With
an irritant contact dermatitis, avoid use of hand lotion before donning gloves;
this may worsen symptoms, as lotions may leach latex proteins from the
gloves. Described as a latex allergy, when clinical manifestations occur within
minutes after exposure to latex, an immediate hypersensitivity (type I)
allergic reaction has occurred.
QUESTION 8: Which is a primary chemical mediator of hypersensitivity?
Correct Response: Histamine
Explanation: Histamine is a primary chemical mediator of hypersensitivity. Secondary

mediators include serotonin, heparin, and bradykinin.
QUESTION 9: The maximum intensity of histamine occurs within which time frame after
contact with an antigen?
Correct Response: 5 to 10 minutes
Explanation: Histamine’s effects peak 5 to 10 minutes after antigen contact. The other
time frames are inaccurate.
QUESTION 10: Which group of mediators initiates the inflammatory response?
Correct Response: Leukotrienes
Explanation: Leukotrienes are a group of chemical mediators that initiate the

inflammatory response. Lymphokines are substances released by sensitized
lymphocytes when they contact specific organs. Mast cells are connective
tissue that contains heparin and histamine in their granules. Prostaglandins
are unsaturated fatty acids that have a wide assortment of biologic activity.
QUESTION 11: Which type of hypersensitivity occurs when the system mistakenly identifies a
normal constituent of the body as foreign?
Correct Response: Cytotoxic
Explanation: Cytotoxic hypersensitivity occurs when the system mistakenly identifies a

normal constituent of the body as foreign. Anaphylactic hypersensitivity is the
most severe immune-mediated reaction. Delayed hypersensitivity occurs 24 to
72 hours after exposure to an allergen. Immune complex hypersensitivity
involves immune complexes that are formed when antigens bind to

antibodies.
QUESTION 12: Which acts as a potent vasoconstrictor and causes bronchial smooth muscle to
contract?
Correct Response: Serotonin
Explanation: Serotonin acts as a potent vasoconstrictor and causes contraction of bronchial

smooth muscle. Bradykinin is a polypeptide with the ability to cause
increased vascular permeability, vasodilation, hypotension, and contraction of
many types of smooth muscle, such as the bronchi. Prostaglandin is a
polypeptide that stimulates nerve fibers and causes pain. Platelet-activating
factor is responsible for initiating platelet aggregation and leukocytes, as well
as vasodilation and increased capillary permeability.
QUESTION 13: Which term refers to an incomplete antigen?
Correct Response: Hapten
Explanation: A hapten is an incomplete antigen. An allergen is a substance that causes

manifestations of allergy. An antigen is a substance that induces the
production of antibodies. An antibody is a protein substance developed by the
body in response to and interacting with a specific antigen.
QUESTION 14: The best treatment for latex allergy is
Correct Response: avoidance of latex-based products.
Explanation: The best treatment available for latex allergy is to avoid latex-based
products, but this is often difficult because of their widespread use.
Antihistamines and an emergency kit containing epinephrine should be
provided to these clients, along with instructions about emergency
management of latex allergy.
QUESTION 15: Which test indicates the quantity of allergen necessary to evoke an allergic
reaction?
Correct Response: Serum-specific IgE test
Explanation: The serum-specific IgE test, formerly known as RAST, is a radioimmunoassay

that measures allergen-specific IgE. It indicates the quantity of allergen
necessary to evoke an allergic reaction. Provocative testing involves the
direct administration of the suspected allergen to the sensitive tissue such as

the conjunctiva. The scratch test does not indicate the quantity of allergen.
QUESTION 16: What is the most common cause of anaphylaxis?
Correct Response: Penicillin
Explanation: Penicillin is the most common pharmacological cause of anaphylaxis and

accounts for about 75% of fatal anaphylactic reactions in the United States
each year. Opioids, NSAIDs, and radiocontrast agents are some of the
medications that are frequently reported as causing anaphylaxis.
QUESTION 17: Which cells present the antigen to T cells and initiate the immune response?
Correct Response: Macrophages
Explanation: Macrophages initiate the immune response. B cells are programmed to

produce one specific antibody. Antigens are substances that induce the
production of antibodies. Haptens are incomplete antigens.
QUESTION 18: Which chemical mediators initiate and mediate the inflammatory response?
Correct Response: Leukotrienes
Explanation: Leukotrienes are chemical mediators from constituents of cell membranes.

Cytokines are nonantibody proteins that act as intercellular mediators, as in
the generation of the immune response. Prostaglandins are lipid-soluble
molecules synthesized from constituents of cell membranes. Complement is a
plasma protein associated with immunologic reactions.
QUESTION 19: The nurse is conducting discharge teaching for a client who is being
discharged from the emergency department after an anaphylactic reaction to
peanuts. Which education should the nurse include in the teaching? Select all
that apply.
Correct Response: Wearing a medical alert bracelet

Avoiding allergens
Explanation: People who have experienced food, medication, idiopathic, or exercise-

induced anaphylactic reactions should make every attempt to strictly avoid
the allergen. Additionally, they should wear a medical alert bracelet and
carry an emergency kit containing epinephrine for injection to prevent the
onset of the reaction on exposure. Sedatives are not used to treat

anaphylactic reactions, and desensitization is not used for peanut allergies.
QUESTION 20: The nurse observes diffuse swelling involving the deeper skin layers in a client
who has experienced an allergic reaction. The nurse would correctly
document this finding as
Correct Response: angioneurotic edema.
Explanation: The area of skin demonstrating angioneurotic edema may appear normal, but
often has a reddish hue and does not pit. Urticaria (hives) is characterized as
edematous skin elevations that vary in size, shape, and itch, which cause
local discomfort. Contact dermatitis refers to inflammation of the skin caused
by contact with an allergenic substance such as poison ivy. Pitting edema, the
result of increased interstitial fluid, is associated with disorders such as
congestive heart failure.
QUESTION 21: The nurse is conducting a community education program on allergies and
anaphylactic reactions. The nurse determines that the participants
understand the education when they make which statement about
anaphylaxis?
Correct Response: The most common cause of anaphylaxis is penicillin.
Explanation: The most common cause of anaphylaxis is penicillin, accounting for about 75%
of fatal anaphylactic reactions in the United States. Although possibly severe,
anaphylactoid reactions are rarely fatal. Food items that are common causes
of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and
wheat. Local reactions usually involve urticaria and angioedema at the site of
the antigen exposure. Systemic reactions, which occur within about 30
minutes of exposure, involve cardiovascular, respiratory, gastrointestinal, and
integumentary organ systems.
QUESTION 22: The nurse is working with a colleague who has a delayed hypersensitivity
(type IV) allergic reaction to latex. Which statement describes the clinical
manifestations of this reaction?
Correct Response: Symptoms are localized to the area of exposure, usually the back of the
hands.
Explanation: Clinical manifestations of a delayed hypersensitivity reaction are localized to

the area of exposure. Clinical manifestations of an irritant contact dermatitis
can be eliminated by changing glove brands or using powder-free gloves. With
an irritant contact dermatitis, avoid use of hand lotion before donning gloves;
this may worsen symptoms, as lotions may leach latex proteins from the
gloves. When clinical manifestations occur within minutes after exposure to

latex, which is described as a latex allergy, an immediate hypersensitivity
(type I) allergic reaction has occurred.
QUESTION 23: The nurse is caring for a client experiencing an anaphylactic reaction. The
nurse prepares for the maximum intensity of histamine response to occur
within which time frame?
Correct Response: 5 to 10 minutes
Explanation: Histamine's effects peak 5 to 10 minutes after antigen contact. The other
time frames are inaccurate.
QUESTION 24: The nurse is creating a discharge teaching plan for a client with a latex
allergy. Which information should be included? Select all that apply.
Correct Response: Administration of emergency epinephrine

Avoidance of latex-based products
Administration of antihistamines
Explanation: The nurse should include in the discharge teaching plan avoidance of latex-
based products. Additionally, the nurse should include administration of
antihistamines and an emergency epinephrine. RAST testing would not be
indicated; it is a diagnostic test for allergies, and the client’s latex allergy is
already diagnosed.
QUESTION 25: The nurse working in the emergency department is asked to explain allergy
testing to a client who experienced an allergic reaction to an unknown
allergen. Which test indicates the quantity of allergen necessary to evoke an
allergic reaction?
Correct Response: Serum-specific IgE test
Explanation: The serum-specific IgE test, formerly known as RAST, is a radioimmunoassay

that measures allergen-specific IgE. It indicates the quantity of allergen
necessary to evoke an allergic reaction. Provocative testing involves the
direct administration of the suspected allergen to the sensitive tissue such as
the conjunctiva. The scratch test does not indicate the quantity of allergen.
QUESTION 26: What is the most common cause of anaphylaxis?
Correct Response: Penicillin
Explanation: Penicillin is the most common cause of anaphylaxis, accounting for about 75%
of fatal anaphylactic reactions in the United States each year. Opioids,
NSAIDs, and radiocontrast agents are some of the medications that are
frequently reported as causing anaphylaxis.
QUESTION 27: The nurse is caring for a client with myasthenia gravis. The nurse generates a
plan of care for the client based on which type of hypersensitivity reaction?
Correct Response: Cytotoxic
Explanation: Cytotoxic hypersensitivity occurs when the body mistakenly identifies a part
of the body as foreign, as in myasthenia gravis, where the body mistakenly
identifies normal nerve endings as foreign. Delayed hypersensitivity reactions
occur 24 to 72 hours after exposure. Immune complex hypersensitivity
involves immune complexes formed when antigens bind to antibodies.
Anaphylactic hypersensitivity is an immediate reaction characterized by
edema in many tissues, often with hypotension, bronchospasm, and
cardiovascular collapse.
QUESTION 28: The nurse is evaluating a client’s complete blood cell count and
differential along with the serum immunoglobulin E (IgE) concentration.
Which result might indicate that the client has an allergic disorder?
Correct Response: High IgE concentration
Explanation: A high total IgE concentration and/or a high percentage of eosinophils may
indicate an allergic disorder. However, normal IgE levels do not exclude the
diagnosis of an allergic disorder. The amounts of neutrophils and white blood
cells are not affected by allergic disorders.
QUESTION 29: The nurse working in an allergy clinic is preparing to administer skin testing
to a client. Which route is the safest for the nurse to use to administer the
solution?
Correct Response: Intradermal
Explanation: The intradermal route is the correct route of administration for skin testing
and therefore a safe route. Another safe route is epicutaneous. The type of
skin testing being performed determines whether the nurse will administer
the solution via the epicutaneous or intradermal route.
QUESTION 30: The nurse is evaluating a client’s readiness for allergy skin testing. The nurse
determines that the testing will need to be postponed when it is revealed
that the client took which classification of medication the night before?
Correct Response: Antihistamine
Explanation: Antihistamines and corticosteroids suppress skin test reactivity and should be
stopped 48 to 96 hours before testing.
QUESTION 31: The nurse is conducting an initial assessment of a hospitalized client who
states that he has a latex allergy. The nurse notes that the skin of the client’s
hands is dry, thick, and cracked. The nurse documents the client’s reaction to
latex as which condition?
Correct Response: Irritant contact dermatitis
Explanation: Dry, thickened, and cracked skin is a symptom of a chronic irritant contact
dermatitis, a common reaction to latex. Symptoms of allergic contact
dermatitis in reaction to latex include pruritus, swelling, crusting and
thickened skin, blisters, and other lesions. Symptoms of latex allergy include
rhinitis, flushing, urticaria, laryngeal edema, bronchospasms, asthma, and
cardiovascular collapse.
QUESTION 32: A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma

symptoms. The nurse educates the client about side effects, which include
Correct Response: adrenal suppression.
Explanation: The nurse should instruct the client that side effects of oral corticosteroid
therapy include adrenal suppression, fluid retention, weight gain, glucose
intolerance, hypertension, and gastric irritation.
QUESTION 33: The nurse is completing the intake assessment of a client new to the allergy
clinic. The client states that he was taking nose drops six times a day to
relieve his nasal congestion. The nasal congestion increased, causing him to
increase his usage of the nasal spray to eight times a day. But again the
congestion worsened. The nurse communicates to the health care provider
that the client experienced
Correct Response: Rhinitis medicamentosa
Explanation: Rhinitis medicamentosa is a rebound reaction from overuse of

sympathomimetic nose drops or sprays that worsen the congestion, causing
the client to use more of the medication, thereby leading to more nasal
congestion. This differs from tolerance, when more medication is needed to
achieve the desired effect. Leukotriene modifiers are a category of
medications used to treat allergies. Atopic dermatitis is a type I

hypersensitivity involving inflammation of the skin evidenced by itching,
erythema, and skin lesions.
Quiz Stats

Answer Key
QUESTION 1: Which term refers to fixation or immobility of a joint?
Correct Response: Ankylosis
Explanation: Ankylosis may result from disease or scarring due to trauma. Hemarthrosis
refers to bleeding into a joint. Diarthrodial refers to a joint with two freely
moving parts. Arthroplasty refers to replacement of a joint.
QUESTION 2: Which term indicates an accumulation of crystalline depositions in articular

surfaces, bones, soft tissue, and cartilage?
Correct Response: Tophi
Explanation: Tophi, when problematic, are surgically excised. Subchondral bone refers to a
bony plate that supports the articular cartilage. Pannus refers to newly
formed synovial tissue infiltrated with inflammatory cells. Joint effusion
refers to the escape of fluid from the blood vessels or lymphatic vessels into
the joint cavity.
QUESTION 3: Which connective tissue disorder is characterized by insoluble collagen being

formed and accumulating excessively in the tissues?
Correct Response: Scleroderma
Explanation: Scleroderma occurs initially in the skin but also occurs in blood vessels, major
organs, and body systems, potentially resulting in death. Rheumatoid arthritis
results from an autoimmune response in the synovial tissue, with damage
taking place in body joints. SLE is an immunoregulatory disturbance that
results in increased autoantibody production. In polymyalgia rheumatic,
immunoglobulin is deposited in the walls of inflamed temporal arteries.
QUESTION 4: Osteoarthritis is known as a disease that

Correct Response: is the most common and frequently disabling of joint disorders.
Explanation: The functional impact of osteoarthritis on quality of life, especially for

elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy
that affects young adult males and is characterized primarily by urethritis,
arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis,
polyarthritis, and spondylitis, requires early treatment because of early
damage caused by disease. Ankylosing spondylitis affects the cartilaginous
joints of the spine and surrounding tissues, making them rigid and decreasing
mobility; it is usually diagnosed in the second or third decade of life.
QUESTION 5: Which newer pharmacological therapy, used to treat osteoarthritis, is thought

to prevent the loss of cartilage and repair chondral defects, as well as have
some anti-inflammatory effects?
Correct Response: Viscosupplementation
Explanation: Viscosupplementation, the intra-articular injection of hyaluronates, is

thought to prevent the loss of cartilage and repair chondral defects. It may
also have some anti-inflammatory effects. Glucosamine and chondroitin are
thought to improve tissue function and retard breakdown of cartilage.
Capsaicin is a topical analgesic.
QUESTION 6: Which is an appropriate nursing intervention in the care of the client with
osteoarthritis?
Correct Response: Encourage weight loss and an increase in aerobic activity
Explanation: Weight loss and an increase in aerobic activity such as walking, with special
attention to quadriceps strengthening, are important approaches to pain
management. Clients should be assisted to plan their daily exercise at a time
when the pain is least severe, or plan to use an analgesic, if appropriate,
before an exercise session. Gastrointestinal complications, especially
bleeding, are associated with the use of nonsteroidal anti-inflammatory
drugs. Topical analgesics such as capsaicin and methylsalicylate may be used
for pain management.
QUESTION 7: The presence of crystals in synovial fluid obtained from arthrocentesis is

indicative of
Correct Response: gout.
Explanation: The presence of crystals is indicative of gout, whereas the presence of

bacteria is indicative of infective arthritis.
QUESTION 8: The result of which diagnostic study is decreased in the client diagnosed with
rheumatoid arthritis?
Correct Response: Red blood cell count
Explanation: Clients diagnosed with rheumatic diseases have a decreased red blood cell
count. ESR is increased in inflammatory connective tissue disease. Uric acid is
increased in gout. Increased creatinine may indicate renal damage in SLE,
scleroderma, and polyarteritis.
QUESTION 9: Which points should be included in the medication teaching plan for a client
taking adalimumab?
Correct Response: It is important to monitor for injection site reactions.
Explanation: It is important to monitor for injection site reactions when taking

adalimumab. The medication is injected subcutaneously and must be
refrigerated. The medication should be withheld if fever occurs.
QUESTION 10: Which is the leading cause of disability and pain in the elderly?
Correct Response: Osteoarthritis (OA)
Explanation: Osteoarthritis is the leading cause of disability and pain in the elderly. RA,
SLE, and scleroderma are not leading causes of disability and pain in the
elderly.
QUESTION 11: Scleroderma typically begins with the involvement of which system?
Correct Response: Integumentary
Explanation: Scleroderma begins with skin involvement. The disease does not begin with
respiratory, urinary, or cardiovascular involvement.
QUESTION 12: Which finding is consistent with the diagnosis of rheumatoid arthritis?
Correct Response: Cloudy synovial fluid
Explanation: In a client with rheumatoid arthritis, arthrocentesis shows synovial fluid that
is cloudy, milky, or dark yellow and contains numerous inflammatory
components, such as leukocytes and complement.
QUESTION 13: Which disorder is characterized by a butterfly-shaped rash across the bridge
of the nose and cheeks?
Correct Response: Systemic lupus erythematosus (SLE)
Explanation: The most familiar manifestation of SLE is an acute cutaneous lesion consisting
of a butterfly-shaped rash across the bridge of the nose and the cheeks. This
type of rash does not characterize RA, scleroderma, or polymyositis.
QUESTION 14: Which joint is most commonly affected in gout?
Correct Response: Metatarsophalangeal
Explanation: The metatarsophalangeal joint of the big toe is the most commonly affected
joint (90% of clients); this is referred to as podagra. The wrists, fingers, and
elbows are less commonly affected. The tarsal area, ankle, and knee are not
the most commonly affected in gout.
QUESTION 15: The side effect of bone marrow depression may occur with which medication
used to treat gout?
Correct Response: Allopurinol
Explanation: A client taking allopurinol needs to be monitored for the side effects of bone
marrow depression, vomiting, and abdominal pain.
QUESTION 16: Fibromyalgia is a common condition that involves
Correct Response: chronic fatigue, generalized muscle aching, and stiffness.
Explanation: Fibromyalgia is a common condition that involves chronic fatigue, generalized

muscle aching, and stiffness. The cause is unknown, and no pathological
characteristics specific for the condition have been identified. Treatment
consists of attention to the specific symptoms reported by the client. NSAIDs
may be used to treat the diffuse muscle aching and stiffness. Tricyclic
antidepressants are used to improve or restore normal sleep patterns, and
individualized programs of exercise are used to decrease muscle weakness
and discomfort and to improve the general deconditioning that occurs in
these individuals.
QUESTION 17: What intervention will best help a client with ankylosing spondylitis (AS)?
Correct Response: Teach the client to use a walker or cane.
Explanation: Ankylosing spondylitis (AS) affects the cartilaginous joints of the spine and
can lead to decreased mobility and stability. Assisting the client to use a
walker or cane will help prevent injury from falls. Range-of-motion exercises
and traction will not help the client. The hallmark of the condition is back
pain and sometimes fractures.
QUESTION 18: The nurse teach the client that osteoarthritis is
Correct Response: the most common and frequently disabling of joint disorders.
Explanation: The functional impact of osteoarthritis on quality of life, especially for

elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy
that affects young adult males and is characterized primarily by urethritis,
arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis,
polyarthritis, and spondylitis, requires early treatment because of early
damage caused by disease. Ankylosing spondylitis affects the cartilaginous
joints of the spine and surrounding tissues and is usually diagnosed in the
second or third decade of life.
QUESTION 19: The nurse teaches the client that the presence of crystals in the synovial fluid
obtained from arthrocentesis confirms which disease process?
Correct Response: Gout
Explanation: The presence of crystals is indicative of gout; the presence of bacteria is

indicative of infective arthritis.
QUESTION 20: Which condition is the leading cause of disability and pain in the elderly?
Correct Response: Osteoarthritis (OA)
Explanation: OA is the leading cause of disability and pain in the elderly. RA, SLE, and
scleroderma are not leading causes of disability and pain in the elderly.
QUESTION 21: Which disorder is characterized by a butterfly-shaped rash across the bridge
of the nose and cheeks?
Correct Response: Systemic lupus erythematous (SLE)
Explanation: The most familiar manifestation of SLE is an acute cutaneous lesion consisting
of a butterfly-shaped rash across the bridge of the nose and the cheeks. This
type of rash does not characterize RA, scleroderma, or polymyositis.
QUESTION 22: The nurse intervenes to assist the client with fibromyalgia to cope with
which symptoms?
Correct Response: Chronic fatigue, generalized muscle aching, and stiffness
Explanation: Fibromyalgia is a common condition that involves chronic fatigue, generalized

muscle aching, and stiffness. The cause is unknown, and no pathologic
characteristics specific for the condition have been identified. Treatment
consists of attention to the specific symptoms reported by the client. NSAIDs
may be used to treat the diffuse muscle aching and stiffness. Tricyclic
antidepressants are used to improve or restore normal sleep patterns, and
individualized programs of exercise are used to decrease muscle weakness
and discomfort and to improve the general deconditioning that occurs in
these individuals.
QUESTION 23: The nurse is caring for a client who is being treated for fibromyalgia. What
intervention will best assist the client to restore normal sleep patterns?
Correct Response: Tricyclic antidepressants
Explanation: Tricyclic antidepressants and sleep hygiene measures are used to improve or
restore normal sleep patterns in clients with fibromyalgia. Increasing activity
during the day or using range-of-motion exercises will not increase the
client’s ability to sleep. Narcotics are generally not needed for pain control
with this disorder.
QUESTION 24: The nurse is teaching a client about rheumatic disease. What statement best
helps to explain autoimmunity?
Correct Response: “Your symptoms are a result of your body attacking itself.”
Explanation: In autoimmunity, the body mistakes its own tissue for foreign tissue and
begins to attack it. Symptoms develop as the body destroys tissue. The body
is in effect attacking itself. The other statements do not explain
autoimmunity.
QUESTION 25: Nursing care for the client with fibromyalgia should be guided by the
assumption that patients with fibromyalgia

Correct Response: may feel as if their symptoms are not taken seriously.
Explanation: Because clients present with widespread symptoms that are often vague in
nature, health care providers may misdiagnose them. Clients feel as though
people are not listening to them. Nurses need to provide support and
encouragement. Symptoms of disease vary from client to client and respond
to different treatments. Clients do not lose their ability to walk.
QUESTION 26: The nurse is caring for a client who has been diagnosed with a “rheumatic
disease.” What nursing diagnoses will most likely apply to this client’s care?
Correct Response: Pain

Fluid and electrolyte imbalance
Fatigue
Alteration of self-concept
Explanation: Clients with rheumatic diseases, which typically involve joints and muscles,
experience problems with mobility, fatigue, and pain. Because of the
limitations of the disease, clients often have an altered self-image and self-
concept. Fluid and electrolyte imbalances are not typically associated with
these types of diseases.
QUESTION 27: A client with rheumatoid arthritis reports joint pain. What intervention is a
priority to assist the client?
Correct Response: Nonsteroidal anti-inflammatory drugs
Explanation: Nonsteroidal anti-inflammatory drugs are the mainstay of treatment for

rheumatoid arthritis pain. They help to decrease inflammation in the joints.
Heat, rather than ice packs, is used to relieve pain. Paraffin baths may also
help. Surgery is reserved for joint replacement when the joint is no longer
functional; it is not an intervention specific to relieving pain.
QUESTION 28: The nurse is performing discharge teaching for a client with rheumatoid
arthritis. What teachings are priorities for the client? Select all that apply.
Correct Response: Assistive devices

Safe exercise
Medication dosages and side effects
Explanation: The client with rheumatoid arthritis who is being discharged to home needs
information on how to exercise safely to maintain joint mobility. Medication
doses and side effects are always an essential part of discharge teaching.
Assistive devices, such as splints, walkers, and canes, may assist the client to
perform safe self-care. Narcotics are not commonly used, and there would be
no reason for dressings.
QUESTION 29: A client is admitted with an acute attack of gout. What interventions are
essential for this client? Select all that apply.
Correct Response: Corticosteroid therapy

Serum uric acid concentration
Pain medication
Probenecid
Explanation: Steroids may be used in clients who have not responsed to other therapies.
They have been shown to decrease inflammation and pain in attacks of gout.
Probenecid will assist in the excretion of uric acid, the causative agent.
Serum uric acid concentrations will guide therapy and treatment. A dietary
consult can wait until the client the acute, painful period is over.
QUESTION 30: What is the priority intervention for a client who has been admitted
repeatedly with attacks of gout?
Correct Response: Assess diet and activity at home
Explanation: Clients with gout need to be educated about dietary restrictions in order to
prevent repeated attacks. Foods high in purine need to be avoided, and
alcohol intake has to be limited. Stressful activities should also be avoided.
The nurse should assess to determine what is stimulating the repeated attacks
of gout. The other interventions are not appropriate for a client with this
problem.
QUESTION 31: What intervention is a priority for a client diagnosed with osteoarthritis?
Correct Response: Physical therapy and exercise
Explanation: Clients with osteoarthritis need to maintain joint mobility. To preserve joint
function, individuals need to learn appropriate activities. Colchicine and
allopurinol are used for gout, not osteoarthritis. Hydrotherapy is not a priority
for care.

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9/22/2020 NCLEX-Style Review Questions

Name: Cezhille Battad Quiz completed in: 5.23 mins

Your Response: Correct!

Correct Response: Consolidation

Explanation: Consolidation occurs during an infectious process such as pneumonia.

QUESTION 2: Which community-acquired pneumonia demonstrates the highest occurrence

Your Response: Correct!

Correct Response: Legionnaires disease

Explanation: Legionnaires disease accounts for 15% of community-acquired pneumonias; it

Your Response: Correct!

Correct Response: redness and induration.

Your Response: Correct!

Correct Response: Record the observation

Your Response: Correct!

Correct Response: Large cell carcinoma

Your Response: Correct!

Correct Response: Adenocarcinoma

Your Response: Correct!

Correct Response: Receiving vaccinations

and influenza infections to receive vaccinations against these infections. The

Your Response: Correct!

Correct Response: Turn onto the affected side.

Your Response: Correct!

Correct Response: Dullness over the involved area

Your Response: Correct!

Correct Response: A diet rich in protein

Your Response: Correct!

Correct Response: Encourage breathing exercises

suspected and clients with confirmed influenza in private rooms or place

Your Response: Correct!

Correct Response: pleural effusion.

Your Response: Correct!

Correct Response: Pneumocystis

Your Response: Correct!

Correct Response: It is most contagious during the second week of illness.

Explanation: Based on available information, SARS is most likely to be contagious only

QUESTION 15: Class 1 with regard to TB indicates

Your Response: Correct!

Correct Response: exposure and no evidence of infection.

Explanation: Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no

QUESTION 16: Resistance to a first-line antituberculotic agent in a client who has not

Your Response: Correct!

Correct Response: primary drug resistance.

Explanation: Primary drug resistance refers to resistance to one of the first-line

Your Response: Correct!

Correct Response: Vitamin B6

Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-

QUESTION 18: Which is a key characteristic of pleurisy?

Your Response: Correct!

Correct Response: Pain

Explanation: The key characteristic of pleuritic pain is its relationship to respiratory

Your Response: Correct!

Correct Response: pH 7.28

Explanation: Acute respiratory failure is defined as a decrease in arterial oxygen tension

QUESTION 20: Which would be least likely to contribute to a case of hospital-acquired

Your Response: Correct!

Your Response: Correct!