CARDIOVASCULAR DISORDER (MEDICAL AND
SURGICAL NURSING)
Instruction: choose the best answer of the
following questions.
1. The client is admitted to the telemetry unit
diagnosed with acute exacerbation of
congestive heart failure (CHF). Which
signs/symptoms would the nurse expect to find
when assessing this client?
A. Apical pulse rate of 110 and 4+ pitting
edema of feet.
B. Thick white sputum and crackles that clear
with cough.
C. The client sleeping with no pillow and
eupnea.
D. Radial pulse rate of 90 and capillary refill
time <3 seconds.
2. The nurse is developing a nursing care plan
for a client diagnosed with congestive
heart failure. A nursing diagnosis of “decreased
cardiac output related to inability of
the heart to pump effectively” is written. Which
short-term goal would be best for the
client? The client will:
A. Be able to ambulate in the hall by date of
discharge.
B. Have an audible S1 and S2 with no S3 heard
by end of shift.
C. Turn, cough, and deep breathe every two
(2) hours.
D. Have a pulse oximeter reading of 98% by
day two (2) of care.
3. The nurse is developing a discharge-teaching
plan for the client diagnosed with
congestive heart failure. Which interventions
should be included in the plan? Select all
that apply.
A. Notify health-care provider of a weight gain
of more than one (1) pound in a week.
B. Teach client how to count the radial pulse
when taking digoxin, a cardiac glycoside.
C. Instruct client to remove the saltshaker from
the dinner table.
D. Encourage client to monitor urine output for
change in color to become dark.
E. Discuss the importance of taking the loop
diuretic furosemide at bedtime.
4. The nurse enters the room of the client
diagnosed with congestive heart failure. The
client is lying in bed gasping for breath, is cool
and clammy, and has buccal cyanosis.
Which intervention would the nurse implement
first?
A. Sponge the client’s forehead.
B. Obtain a pulse oximetry reading.
C. Take the client’s vital signs.
D. Assist the client to a sitting position.
5. The nurse is assessing the client diagnosed
with congestive heart failure. Which
signs/symptoms would indicate that the
medical treatment has been effective?
A. The client’s peripheral pitting edema has
gone from 3+ to 4+.
B. The client is able to take the radial pulse
accurately.
C. The client is able to perform ADLs without
dyspnea.
D. The client has minimal jugular vein
distention.
6. The nurse is assessing the client diagnosed
with congestive heart failure. Which
laboratory data would indicate that the client is
in severe congestive heart failure?
A. An elevated B-type natriuretic peptide (BNP).
B. An elevated creatine kinase (CK-MB).
C. A positive D-dimer.
D. A positive ventilation/perfusion (V/Q) scan.
7. The health-care provider has ordered an
angiotensin-converting enzyme (ACE)
inhibitor for the client diagnosed with
congestive heart failure. Which discharge
instructions should the nurse include?
A. Instruct the client to take a cough
suppressant if a cough develops.
B. Teach the client how to prevent orthostatic
hypotension.
C. Encourage the client to eat bananas to
increase potassium level.
D. Explain the importance of taking the
medication with food.
8. The nurse on the telemetry unit has just
received the a.m. shift report. Which client
should the nurse assess first?
A. The client diagnosed with myocardial
infarction who has an audible S3 heart
a. sound.
B. The client diagnosed with congestive heart
failure who has 4+ sacral pitting
a. edema.
C. The client diagnosed with pneumonia who
has a pulse oximeter reading of 94%.
D. The client with chronic renal failure who has
an elevated creatinine level.
9. The nurse and an unlicensed assistive
personnel (UAP) are caring for four clients on
a telemetry unit. Which nursing task would be
best for the nurse to delegate to the
UAP?
A. Assist the client to go down to the smoking
area for a cigarette.
B. Transport the client to the intensive care unit
via a stretcher.
C. Provide the client going home discharge-
teaching instructions.
D. Help position the client who is having a
portable x-ray done.
10. The charge nurse is making shift
assignments for the medical floor. Which client
should be assigned to the most experienced
registered nurse?
A. The client diagnosed with congestive heart
failure who is being discharged in the
morning.
B. The client who is having frequent incontinent
liquid bowel movements and vomiting.
C. The client with an apical pulse rate of 116, a
respiratory rate of 26, and a blood
pressure of 94/62.
D. The client who is complaining of chest pain
with inspiration and a nonproductive
cough.
11. The client diagnosed with congestive heart
failure is complaining of leg cramps at
night. Which nursing interventions should be
implemented?
A. Check the client for peripheral edema and
make sure the client takes a diuretic
early in the day.
B. Monitor the client’s potassium level and
assess the client’s intake of bananas and
orange juice.
C. Determine if the client has gained weight
and instruct the client to keep the legs
elevated.
D. Instruct the client to ambulate frequently
and perform calf-muscle stretching
exercises daily.
12. The nurse has written an outcome goal
“demonstrates tolerance for increased
activity” for a client diagnosed with congestive
heart failure. Which intervention
should the nurse implement to assist the client
to achieve this outcome?
A. Measure intake and output.
B. Provide two (2)-g sodium diet.
C. Weigh client daily.
D. Plan for frequent rest periods.
13. Which cardiac enzyme would the nurse
expect to elevate first in a client diagnosed
with a myocardial infarction?
A. Creatine kinase (CK-MB).
B. Lactate dehydrogenase (LDH).
C. Troponin.
D. White blood cells (WBCs).
14. Along with persistent, crushing chest pain,
which signs/symptoms would make the
nurse suspect that the client is experiencing a
myocardial infarction?
A. Midepigastric pain and pyrosis.
B. Diaphoresis and cool clammy skin.
C. Intermittent claudication and pallor.
D. Jugular vein distention and dependent
edema.
15. The client diagnosed with rule-out
myocardial infarction is experiencing chest pain
while walking to the bathroom. Which action
should the nurse implement first?
A. Administer sublingual nitroglycerin.
B. Obtain a STAT electrocardiogram.
C. Have the client sit down immediately.
D. Assess the client’s vital signs.
16. The nurse is caring for a client diagnosed
with a myocardial infarction who is
experiencing chest pain. Which interventions
should the nurse implement? Select all
that apply.
A. Administer morphine intramuscularly.
B. Administer an aspirin orally.
C. Apply oxygen via a nasal cannula.
D. Place the client in a supine position.
E. Administer nitroglycerin subcutaneously.
17. The client who has had a myocardial
infarction is admitted to the telemetry unit
from intensive care. Which referral would be
most appropriate for the client?
A. Social worker.
B. Physical therapy.
C. Cardiac rehabilitation.
D. Occupational therapy.
18. The client is one (1) day postoperative
coronary artery bypass surgery. The client
complains of chest pain. Which intervention
should the nurse implement first?
A. Medicate the client with intravenous
morphine.
B. Assess the client’s chest dressing and vital
signs.
C. Encourage the client to turn from side to
side.
D. Check the client’s telemetry monitor.
19. The client diagnosed with a myocardial
infarction is six (6) hours post–right femoral
percutaneous transluminal coronary
angioplasty (PTCA), also known as balloon
surgery. Which assessment data would require
immediate intervention by the nurse?
A. The client is keeping the affected extremity
straight.
B. The pressure dressing to the right femoral
area is intact.
C. The client is complaining of numbness in the
right foot.
D. The client’s right pedal pulse is 3+ and
bounding.
20. The intensive care department nurse is
assessing the client who is 12 hours post–
myocardial infarction. The nurse assesses an S3
heart sound. Which intervention should the
nurse implement?
A. Notify the health-care provider immediately.
B. Elevate the head of the client’s bed.
C. Document this as a normal and expected
finding.
D. Administer morphine intravenously.
21. The nurse is administering a calcium
channel blocker to the client diagnosed with a
myocardial infarction. Which assessment data
would cause the nurse to question
administering this medication?
A. The client’s apical pulse is 64.
B. The client’s calcium level is elevated.
C. The client’s telemetry shows occasional
PVCs.
D. The client’s blood pressure is 90/62.
22. The client diagnosed with a myocardial
infarction is on bedrest. The unlicensed
assistive personnel (UAP) is encouraging the
client to move the legs. Which action
should the nurse implement?
A. Instruct the UAP to stop encouraging the leg
movements.
B. Report this behavior to the charge nurse as
soon as possible.
C. Praise the UAP for encouraging the client to
move legs.
D. Take no action concerning the UAP’s
behavior.
23. The client diagnosed with a myocardial
infarction asks the nurse, “Why do I have to
rest and take it easy? My chest doesn’t hurt
anymore.” Which statement would be
the nurse’s best response?
A. “Your heart is damaged and needs about
four (4) to six (6) weeks to heal.”
B. “There is necrotic myocardial tissue that puts
you at risk for dysrhythmias.”
C. “Your doctor has ordered bedrest. Therefore,
you must stay in the bed.”
D. “Just because your chest doesn’t hurt anymore
doesn’t mean you are out of
danger.”
24. The client has just returned from a cardiac
catheterization. Which assessment data
would warrant immediate intervention from
the nurse?
a. The client’s BP is 110/70 and pulse
is 90.
b. The client’s groin dressing is dry
and intact.
c. The client refuses to keep the leg
straight.
d. The client denies any numbness
and tingling.
25. The male client is diagnosed with coronary
artery disease (CAD) and is prescribed
sublingual nitroglycerin. Which statement
indicates the client needs more teaching?
a. “I should keep the tablets in the
dark-colored bottle they came in.”
b. “If the tablets do not burn under
my tongue, they are not effective.”
c. “I should keep the bottle with me in
my pocket at all times.”
d. “If my chest pain is not gone with
one tablet, I will go to the ER.”
26. The client with coronary artery disease asks
the nurse, “Why do I get chest pain?”
Which statement would be the most
appropriate response by the nurse?
A. “Chest pain is caused by
decreased oxygen to the heart
muscle.”
B. “There is ischemia to the
myocardium as a result of
hypoxemia.”
C. “The heart muscle is unable to
pump effectively to perfuse the
body.”
D. “Chest pain occurs when the
lungs cannot adequately
oxygenate the blood.”
27. The client is scheduled for a right femoral
cardiac catheterization. Which nursing
intervention should the nurse implement after
the procedure?
A. Perform passive range-of-motion
exercises.
B. Assess the client’s neurovascular
status.
C. Keep the client in high Fowler’s
position.
D. Assess the gag reflex prior to
feeding the client.
28. The nurse is preparing to administer a beta
blocker to the client diagnosed with
coronary artery disease. Which assessment
data would cause the nurse to question
administering the medication?
a. The client has a BP of 110/70.
b. The client has an apical pulse of 56.
c. The client is complaining of a
headache.
d. The client’s potassium level is 4.5
mEq/L.
29. Which intervention should the nurse
implement when administering a loop diuretic
to a client diagnosed with coronary artery
disease?
a. Assess the client’s radial pulse.
b. Assess the client’s serum potassium
level.
c. Assess the client’s glucometer
reading.
d. Assess the client’s pulse oximeter
reading.
30. Which client teaching should the nurse
implement for the client diagnosed with
coronary artery disease? Select all that apply.
a. Encourage a low-fat, low-
cholesterol diet.
b. Instruct client to walk 30 minutes a
day.
c. Decrease the salt intake to two (2)
g a day.
d. Refer to counselor for stress
reduction techniques.
e. Teach the client to increase fiber in
the diet.
31. The elderly client has coronary artery
disease. Which question should the nurse ask
the client during the client teaching?
a. “Do you have a daily bowel
movement?”
b. “Do you get yearly chest x-rays?”
c. “Are you sexually active?”
d. “Have you had any weight change?”
32. The nurse is discussing the importance of
exercise with the client diagnosed with
coronary artery disease. Which intervention
should the nurse implement?
a. Perform isometric exercises daily.
b. Walk for 15 minutes three (3) times
a week.
c. Do not walk outside if it is less than
40˚F.
d. Wear open-toed shoes when
ambulating.
33. The nurse is discussing angina with a client
who is diagnosed with coronary artery
disease. Which action should the client take
first when experiencing angina?
a. Put a nitroglycerin tablet under the
tongue.
b. Stop the activity immediately and
rest.
c. Document when and what activity
caused angina.
d. Notify the health-care provider
immediately.
34. The client with coronary artery disease is
prescribed a Holter monitor. Which
intervention should the nurse implement?
a. Instruct client to keep a diary of
activity, especially when having
chest pain.
b. Discuss the need to remove the
Holter monitor during a.m. care and
showering.
c. Explain that all medications should
be withheld while wearing a Holter
monitor.
d. Teach the client the importance of
decreasing activity while wearing
the monitor.
35. Which statement by the client diagnosed
with coronary artery disease indicates that
the client understands the discharge teaching
concerning diet?
a. “I will not eat more than six (6)
eggs a week.”
b. “I should bake or grill any meats I
eat.”
c. “I will drink eight (8) ounces of
whole milk a day.”
d. “I should not eat any type of pork
products.”
36. The charge nurse is making assignments for
clients on a cardiac unit. Which client
should the charge nurse assign to a new
graduate nurse?
a. The 44-year-old client diagnosed
with a myocardial infarction.
b. The 65-year-old client admitted
with unstable angina.
c. The 75-year-old client scheduled for
a cardiac catheterization.
d. The 50-year-old client complaining
of chest pain.
37. A client is being seen in the clinic to R/O
mitral valve stenosis. Which assessment
data would be most significant?
 a. The client complains of shortness of
breath when walking.
b. The client has jugular vein
distention and 3+ pedal edema.
c. The client complains of chest pain
after eating a large meal.
d. The client’s liver is enlarged and the
abdomen is edematous.
38. Which assessment data would the nurse
expect to auscultate in the client diagnosed
with mitral valve insufficiency?
a. A loud S1, S2 split, and a mitral
opening snap.
b. A holosystolic murmur heard best at
the cardiac apex.
c. A midsystolic ejection click or
murmur heard at the base.
d. A high-pitched sound heard at the
third left intercostal space.
39. The client has just received a mechanical
valve replacement. Which behavior by the
client indicates the client needs more teaching?
a. The client takes prophylactic
antibiotics.
b. The client uses a soft-bristle
toothbrush.
c. The client takes an enteric-coated
aspirin daily.
d. The client alternates rest with
activity.
40. The nurse is teaching a class on valve
replacements. Which statement identifies a
disadvantage of having a biological tissue valve
replacement?
a. The client must take lifetime
anticoagulant therapy.
b. The client’s infections are easier to
treat.
c. There is a low incidence of
thromboembolism.
d. The valve has to be replaced
frequently.
41. The nurse is preparing to administer
warfarin (Coumadin), an oral anticoagulant, to
a client with a mechanical valve replacement.
The client’s international normalized
ratio (INR) is 2.7. Which action should the
nurse implement?
a. Administer the medication as
ordered.
b. Prepare to administer vitamin K
(AquaMephyton).
c. Hold the medication and notify the
HCP.
d. Assess the client for abnormal
bleeding.
42. Which signs/symptoms should the nurse
assess in any client who has a long-term
valvular heart disease? Select all that apply.
a. Paroxysmal nocturnal dyspnea.
b. Orthopnea.
c. Cough.
d. Pericardial friction rub.
e. Pulsus paradoxus.
43. The client is being evaluated for valvular
heart disease. Which information would be
most significant?
a. The client has a history of coronary
artery disease.
b. There is a family history of valvular
heart disease.
c. The client has a history of smoking
for 10 years.
d. The client has a history of
rheumatic heart disease.
44. The client who has just had a percutaneous
balloon valvuloplasty is in the recovery
room. Which intervention should the recovery
room nurse implement?
a. Assess the client’s chest tube
output.
b. Monitor the client’s chest dressing.
c. Evaluate the client’s endotracheal
(ET) lip line.
d. Keep the client’s affected leg
straight.
45. The client with a mechanical valve
replacement asks the nurse, “Why do I have to
take antibiotics before getting my teeth
cleaned?” Which response by the nurse is
most appropriate?
a. “You are at risk of developing an
infection in your heart.”
b. “Your teeth will not bleed as much
if you have antibiotics.”
c. “This procedure may cause your
valve to malfunction.”
d. “Antibiotics will prevent vegetative
growth on your valves.”
46. The client had open-heart surgery to
replace the mitral valve. Which intervention
should the intensive care unit nurse
implement?
a. Restrict the client’s fluids as
ordered.
b. Keep the client in the supine
position.
c. Maintain oxygen saturation at 90%.
 d. Monitor the total parenteral
nutrition.
47. Which client would the nurse suspect of
having a mitral valve prolapse?
a. A 60-year-old female with
congestive heart failure.
b. A 23-year-old male with Marfan’s
syndrome.
c. An 80-year-old male with atrial
fibrillation.
d. A 33-year-old female with Down
syndrome.
48. The charge nurse is making shift
assignments. Which client would be most
appropriate for the charge nurse to assign to a
new graduate who just completed
orientation to the medical floor?
a. The client admitted for diagnostic
tests to rule out valvular heart
disease.
b. The client three (3) days post–
myocardial infarction being
discharged tomorrow.
c. The client exhibiting
supraventricular tachycardia (SVT)
on telemetry.
d. The client diagnosed with atrial
fibrillation who has an INR of five
(5).
49. The telemetry nurse is unable to read the
telemetry monitor at the nurse’s station.
Which intervention should the telemetry nurse
implement first?
a. Go to the client’s room to check the
client.
b. Instruct the primary nurse to assess
the client.
c. Contact the client on the client call
system.
d. Request the nursing assistant to
take the crash cart to the client’s
room.
50. The client shows ventricular fibrillation on
the telemetry at the nurse’s station.
Which action should the telemetry nurse
implement first?
a. Administer epinephrine IVP.
b. Prepare to defibrillate the client.
c. Call a STAT code.
d. Start cardiopulmonary resuscitation.
51. The client is experiencing multifocal
premature ventricular contractions. Which
antidysrhythmic medication would the nurse
expect the health-care provider to order
for this client?
a. Lidocaine.
b. Atropine.
c. Digoxin.
d. Adenosine.
52. The client is exhibiting sinus bradycardia, is
complaining of syncope and weakness,
and has a BP of 98/60. Which collaborative
treatment should the nurse anticipate
being implemented?
a. Administer a thrombolytic
medication.
b. Assess the client’s cardiovascular
status.
c. Prepare for insertion of a
pacemaker.
d. Obtain a permit for synchronized
cardioversion.
53. Which intervention should the nurse
implement when defibrillating a client who is
in ventricular fibrillation?
a. Defibrillate the client at 50, 100,
and 200 joules.
b. Do not remove the oxygen source
during defibrillation.
c. Place petroleum jelly on the
defibrillator pads.
d. Shout “all clear” prior to
defibrillating the client.
54. The client has chronic atrial fibrillation.
Which discharge teaching should the nurse
discuss with the client?
a. Instruct the client to use a soft-
bristle toothbrush.
b. Discuss the importance of getting a
monthly partial thromboplastin time
(PTT).
c. Teach the client about signs of
pacemaker malfunction.
d. Explain to the client the procedure
for synchronized cardioversion.
55. The client is exhibiting ventricular
tachycardia. Which intervention should the
nurse
implement first?
a. Administer lidocaine, an
antidysrhythmic, IVP.
b. Prepare to defibrillate the client.
c. Assess the client’s apical pulse and
blood pressure.
d. Start basic cardiopulmonary
resuscitation.
56. The client is in complete heart block. Which
intervention should the nurse
implement first?
a. Prepare to insert a pacemaker.
 b. Administer atropine, an
antidysrhythmic.
c. Obtain a STAT electrocardiogram
(ECG).
d. Notify the health-care provider.
57. The client is in ventricular fibrillation.
Which interventions should the nurse
implement? Select all that apply.
a. Start cardiopulmonary resuscitation.
b. Prepare to administer the
antidysrhythmic adenosine IVP.
c. Prepare to defibrillate the client.
d. Bring the crash cart to the bedside.
e. Prepare to administer the
antidysrhythmic amiodarone IVP.
58. The client who is one (1) day postoperative
coronary artery bypass surgery is
exhibiting sinus tachycardia. Which
intervention should the nurse implement?
a. Assess the apical heart rate for one
(1) full minute.
b. Notify the client’s cardiac surgeon.
c. Prepare the client for synchronized
cardioversion.
d. Determine if the client is having
pain.
59. The client’s telemetry reading shows a P
wave before each QRS complex and the rate
is 78. Which action should the nurse
implement?
a. Document this as normal sinus
rhythm.
b. Request a 12-lead
electrocardiogram.
c. Prepare to administer the
cardiotonic digoxin PO.
d. Assess the client’s cardiac enzymes.
60. Which client problem has priority for the
client with a cardiac dysrhythmia?
a. Alteration in comfort.
b. Decreased cardiac output.
c. Impaired gas exchange.
d. Activity intolerance.
61. The client is diagnosed with pericarditis.
Which are the most common
signs/symptoms the nurse would expect to find
when assessing the client?
a. Pulsus paradoxus.
b. Complaints of fatigue and
arthralgias.
c. Petechiae and splinter
hemorrhages.
d. Increased chest pain with
inspiration.
62. The client is diagnosed with acute
pericarditis. Which sign/symptom warrants
immediate attention by the nurse?
a. Muffled heart sounds.
b. Nondistended jugular veins.
c. Bounding peripheral pulses.
d. Pericardial friction rub.
63. The client is admitted to the medical unit to
rule out carditis. Which question should
the nurse ask the client during the admission
interview to support this diagnosis?
a. “Have you had a sore throat in the
last month?”
b. “Did you have rheumatic fever as a
child?”
c. “Do you have a family history of
carditis?”
d. “What over-the-counter (OTC)
medications do you take?”
64. The client with pericarditis is prescribed a
nonsteroidal anti-inflammatory drug
(NSAID). Which teaching instruction should the
nurse discuss with the client?
a. Explain the importance of tapering
off the medication.
b. Discuss that the medication will
make the client drowsy.
c. Instruct the client to take the
medication with food.
d. Tell the client to take the
medication when the pain level is
around “8.”
65. The client diagnosed with pericarditis is
complaining of increased pain. Which
intervention should the nurse implement first?
a. Administer oxygen via nasal
cannula.
b. Evaluate the client’s urinary output.
c. Assess the client for cardiac
complications.
d. Encourage the client to use the
incentive spirometer.
66. The client diagnosed with pericarditis is
experiencing cardiac tamponade. Which
collaborative intervention should the nurse
anticipate for this client?
a. Prepare for a pericardiocentesis.
b. Request STAT cardiac enzymes.
c. Perform a 12-lead
electrocardiogram.
d. Assess the client’s heart and lung
sounds.
67. The female client is diagnosed with
rheumatic fever and prescribed penicillin, an
antibiotic. Which statement indicates the client
needs more teaching concerning the
discharge teaching?
a. “I must take all the prescribed
antibiotics.”
b. “I may get a vaginal yeast infection
with penicillin.”
c. “I will have no problems as long as
I take my medication.”
d. “My throat culture was positive for
a streptococcal infection.”
68. Which potential complication should the
nurse assess for in the client with infective
endocarditis who has embolization of
vegetative lesions from the mitral valve?
a. Pulmonary embolus.
b. Cerebrovascular accident.
c. Hemoptysis.
d. Deep vein thrombosis.
69. Which nursing diagnosis would be priority
for the client diagnosed with
myocarditis?
a. Anxiety related to possible long-
term complications.
b. High risk for injury related to
antibiotic therapy.
c. Increased cardiac output related to
valve regurgitation.
d. Activity intolerance related to
impaired cardiac muscle function.
70. The client diagnosed with pericarditis is
being discharged home. Which intervention
should the nurse include in the discharge
teaching?
a. Be sure to allow for uninterrupted
rest and sleep.
b. Refer client to outpatient
occupational therapy.
c. Maintain oxygen via nasal cannula
at two (2) L/min.
d. Discuss upcoming valve
replacement surgery