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 61. The elderly client on the cardiac unit was found on the floor by the bed. Which
information should the nurse document in the client’s chart?

1. Fell. No injuries noted. Incident report completed. HCP notified.

2. Found on floor. No complaints of pain. Able to move all extremities.
3. States no one answered call light, so attempted to get up without help.
4. Got out of bed without assistance and fell by the bedside.

62. The home health (HH) nurse is caring for an elderly client. Which nursing task
should the nurse delegate to the HH aide?

1. Cook and freeze meals for the client.

2. Assist the client to sit on the front porch.
3. Take the client for outings to the store.
4. Monitor the client’s mental status.

63. The client admitted to rule out (R/O) a myocardial infarction is complaining of
substernal chest pain radiating to the left arm and jaw. Which intervention should
the nurse implement first?
1. Take the client’s pulse, respirations, and blood pressure.
2. Call for a stat electrocardiogram and a troponin level.
3. Place sublingual nitroglycerin 1/150 g under the tongue.
4. Notify the HCP that the client has pain.

64. The client on the cardiac unit has a cardiac arrest. Which is the administrative
supervisor nurse’s first intervention during the code?
1. Begin to take notes to document the code.
2. Make sure all the jobs are being done.
3. Arrange for an intensive care unit bed.
4. Administer the emergency medications.

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 65. Which client should the cardiac nurse assess first after receiving the p.m. shift
report?

1. The client who is completing the second unit of PRBCs.

2. The client who is crying after being informed of a terminal diagnosis.
3. The client who refused to eat the dietary tray but got food from home.
4. The client who became short of breath ambulating in the hallway.

66. The nurse is caring for Mr. A.B., a client on a telemetry unit. At 0830 the client
complains of chest pain. Which medication should the nurse administer?

1. Administer 1/2 inch of nitroglycerin transdermally now.

2. Morphine sulfate 2 mg IVP STAT.
3. Oxycodone 7.5 mg/acetaminophen 325 mg PO now.
4. Nitroglycerin 0.4 mg sublingual STAT.

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 67. The charge nurse on a cardiac unit has received laboratory reports to assess. Which
lab report is priority for the charge nurse to assess?

1. Ms. C.T., who is on a heparin drip.

2. Mr. R.S., who is scheduled for a coronary artery bypass graft (CABG) this
morning.

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 3. Ms. T.R., who had a cardiac cauterization 18 hours ago.

4. Mr. J.E., who was admitted to rule out gallbladder disease.

68. The nurse on a medical unit is making rounds after receiving the shift report. Which
client should the nurse see first? Rank in order of priority.

1. The 45-year-old client who complained of having chest pain at midnight last night
and received NTG sublingually.
2. The 62-year-old client who is complaining that no one answered the call light for
2 hours yesterday.
3. The 29-year-client diagnosed with septicemia who called to request more blankets
because of being cold.
4. The 78-year-old client diagnosed with dementia whose daughter is concerned
because the client is more confused today.
5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to
be changed this morning.

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 69. While ambulating in the hallway with the nurse, the client diagnosed with myocardial
infarction complains of chest pain. Which interventions should the nurse implement?
Select all that apply.

1. Administer nitroglycerin 0.4 mg sublingual STAT.

2. Have the client walk back to the room.
3. Take the client’s vital signs.
4. Place the client on supplemental oxygen.
5. Ask the ward secretary to call the healthcare provider for orders.

70. The nurse received an aPTT report on a client receiving heparin via continuous
drip infusion. According to the report, the client’s drip rate should be decreased by
100 units per hour. The heparin comes prepared as 25,000 units in 500 mL of fluid.
The current rate of infusion is 26 mL per hour. At what rate should the nurse set the
pump? ___________________

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61
Answer is 2. The nurse should document exactly what was observed. This statement is the correct
documentation.

MAKING NURSING DECISIONS: The nurse must be able to document nursing care safely; it includes accurate,
timely documentation; it meets professional, legislative, and agency standards; it facilitates communication
between nurses and other healthcare providers; and it is comprehensive

62
Answer is 2. The home health aide is responsible for assisting the client with activities of daily living and
transferring from the bed to the chair. Sitting outside is good for the client and is a task that can be
delegated to the home health aide

MAKING NURSING DECISIONS: When the test taker is deciding which option is the most appropriate task to
delegate/assign, the test taker should choose the task that allows each staff member to function within his
or her full scope of practice. Do not assign a task to a staff member that falls outside the staff member’s or
volunteer’s expertise. Remember the RN cannot delegate assessment, teaching, evaluation, medications, or
an unstable client to the UAP.

63
Answer is 3. Placing nitroglycerin under the client’s tongue may relieve the client’s chest pain and provide
oxygen to the heart muscle. This is the nurse’s first intervention

MAKING NURSING DECISIONS: The nurse should remember that if a client is in distress and the nurse can do
something to relieve the distress, that action should be done first, before assessment. The test taker should
select an option that directly helps the client’s condition.

64
Answer is 2. The first intervention for the supervisor is to ensure that all the jobs in the code are being filled.

MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each member of the
multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the
NCLEX-RN® exam. The administrative manager is responsible for the other members of the healthcare team

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65
Answer is 2. The client has been given devastating news. When all the information in the options is expected
and not life threatening, then psychological issues have priority. This client should be seen first.

MAKING NURSING DECISIONS: The test taker must determine if the assessment data is normal or abnormal
for the client’s diagnosis or situation. If the data is abnormal then this client should be seen first. If the data
is normal then a client with a psychosocial problem is the client the nurse should assess first.

66.
Answer is 4. .The nurse should administer the medication that will have the most rapid onset and directly
resolve the problem. Nitroglycerin is a potent vasodilator and will dissolve rapidly under the tongue
(sublingually).

MAKING NURSING DECISIONS: This is an alternate type question included in the NCLEX-RN® blueprint. The
test taker must be able to read a medication administration record (MAR), be knowledgeable of
medications, and be able to make an appropriate decision as to the nurse’s most appropriate intervention.

67.
Answer is 2. This client is scheduled for surgery this morning; therefore, the charge nurse must make sure
that he is stable for the procedure and notify the surgeon if there is any reason to question the safety of the
client having the procedure this morning.

MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN® blueprint.
The test taker must be able to read a chart, be knowledgeable of laboratory data, and be able to make
appropriate decisions as to the nurse’s most appropriate action.

68. Correct Answer: 3, 1, 4, 2, 5

3. This client may be chilling, indicting a potential rise in temperature. The nurse should assess the client and
the temperature to see if interventions should be initiated based on a progression of the septicemia.
1. This client should be assessed to be sure that the client is stable because there was chest pain during the
last shift.
4. The nurse should assess the client next because although confusion is expected, the nurse must
determine whether any new situation is occurring.
2. This client has a psychosocial need but it must be addressed and steps implemented to resolve the
problem.
5. A dressing change can take some time to complete. This is a physiological situation but not a life-
threatening one and the nurse should see this client when he/she has time to perform the dressing change.

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MAKING NURSING DECISIONS: This is an alternate type of question which requires the nurse to assess
clients in order of priority. This requires the nurse to evaluate each client’s situation and determine which
situations are life threatening, which situations are expected for the client’s situation, or which client has a
psychosocial problem.

69
1, 3, and 4 are correct

1.Nitroglycerin tablets are vasodilators that are administered to dilate the coronary vessels and
provide oxygen to the heart muscle.

3. The nurse should assess the client’s vital signs as part of the assessment of the client’s current
situation.

4. Supplemental oxygen will assist in getting higher concentrations of oxygen to the heart muscle.

70. Answer: 24 mL per hour 25,000 divided by 500 mL = 50 units of heparin per mL. 26 (current rate) 50 =
1300 units of heparin currently infusing. 1300 100 = 1200 units of heparin needed as new infusion rate. 1200
divided by 50 = 24 mL per hour to infuse

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