1.

Concerted work efforts among members of the surgical team is essential to the success of
the surgical procedure. The sterile nurse or sterile personnel touch only sterile supplies and instruments.
When there is a need for sterile supply which is not in the sterile field, who handsout these items by
opening its outer cover?
a. Circulating nurse
b. Anesthesiologist
c Surgeon
d. Nursing aide

2. The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. White the surgeon performs the surgical
procedure, who monitors the status of the client like urine output, blood loss?
a. Scrub nurse
b. Surgeon
C. Anesthesiologist
d.Circulating nurse

3. The nurse is assessing the client recently returned from surgery., the nurse is aware that the
best way to assess the pain is to:
a. Take the blood pressure, pulse and temperature
b. Ask the client to rate his pain on a scale of 0-5
c. Watch the client's facial expression
d. Ask the client if he/she is pain

4. Which of the following should be given highest priority when receiving patient in the OR?
a. Assess level of consciousness
b. Verify patient identification and informed consent
c. Assess vital signs
d. Check for jewelry, gown, manicure and dentures

5. The nurse is preparing a client for surgery, which items is most important to remove before
sending the client to surgery?
a. Hearing aid
b. Contact lenses
c. Artificial eye
d. None of the choices

6. nurse kyla is assessing the renal function of a client, after directly noting urine volume and
characteristics, nurse kyla assesses which item as the best indirect indicator of renal function

a body temperature
b blood pressure
d. respiratory rate
7. Which of the following methods should be used to collect a specimen for urine culture?
a Have the client void in a clean container
b clean the foreskin of the penis of uncircumcised men before specimen collection.
c Have the client void into a urinal, and then pour the urine into the specimen container
d Have the client begin the stream of urine in the toilet and catch the urine in a sterile container
midstream

8. A 25-year-old male is admitted to the medical-surgical unit with a diagnosis of nephrotic

syndrome. Which of the following is a hallmark of this syndrome?
a. osmotic diuresis
c. hypolipidemia
b, edema
d. hyperproteinemia

9. A 6-year-old child with nephrotic syndrome has been hospitalized. She presents with a
distended abdomen; periorbital edema, proteinuria, anorexia, and fatigue. Which nursing
measure would be most appropriate?
a. a high sodium diet
b. daily walks or exercises
c. promotion of adequate fluid intake
d. daily measurement of weight and abdominal girth.

10. A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of Fluid Volume
Excess related to fluid accumulation in the tissues. Which of the following would the nurse
anticipate including in the child's plan of care?
a. Maintaining strict bed rest.
b. Weighing the child before breakfast.
Limiting visitors to 2 to 3 hours a day.
d. Testing urine specific gravity every shift.

11. A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses
which most important parameter on a daily basis?
a weight
b. albumin levels
C. BUN level
d. sore throat infection

12. The urinalysis of a toddler diagnosed with nephrotic syndrome reveals +4 for protein.
The nurse interprets this result as indicating which of the following?
a. Loss of red blood cells in the urine.
b. Decreased secretion of aldosterone.
c. Increased glomerular permeability to albumin.
d. Inhibited tubular reabsorption of sodium and water.

13. Which of the following laboratory findings would be present in nephrotic syndrome?
a, decreased serum creatinine
c. decreased serum protein
b. increased serum albumin
d. increased hemoglobin

14. The clinical manifestations of nephrotic syndrome include which of the following?
a. hematuria
©. increased serum albumin
b. massive proteinuria
d. weight loss

15. Which of the following statements by the mother of a toddler diagnosed with nephrotic
sundrome indicates that the mother has understood the nurse's teaching about this disease?
A. "My child really likes chips. I guess we'll have to find something else.
b. "We'll have to encourage lots of liquids. Did you say about 4 liters every dav?"
C. "'We worry about the surgery. Do you think we should do direct donation of blood?"
d. “We understand the need for antibiotics. I just wish that it should be discontinued after
symptoms subside.

16. The mother of a toddler with nephrotic syndrome asks the nurse what can be done about the child's
swollen eyes. Which of the following Would the nurse suggest?
a. Applying eye drops every 8 hours.
b. Elevating the head of the child's bed.
C. Limiting the child's television watching.
d. Applying cool compresses to the child's eyes.

17. The toddler with nephrotic syndrome responds to treatment and is ready to go home
When helping the family plan for home care, which of the following instructions would the
nurse include in the teaching?
a. Administer pain medication as needed.
b. Administer Acetaminophen (Tylenol) daily.
c. Keep the child away from others with an infection.
d. Notify the physician if there is an increase in the child's urine output.

18. During hospitalization, a client with glomerulonephritis and oliguria asks for food from home After
teaching the mother about diet, the nurse determines that the teaching had been effective when the
mother brings in which of the following?
a. pizza and cola
c. ice cream sundae
b. hamburger and fries
d. strawberries and kiwi

19. When developing the plan of care for a school-aged child with glomerulonephritis who has a fluid
restriction of 1000 mL/day, which of the following fluids would the nurse consider as most appropriate
for the client's condition and effective for preventing excessive thirst?
a. diet cola
c lemonade
b. ice chips
d tap water

20. A client hospitalized with glomerulonephritis during the acute stage has elevated blood
pressure and low urine output for 14 hours. Which of the following would the nurse do next?
a. Assess the client's neurologic status.
b. Encourage the client to drink more water.
c. Help the client to ambulate in the hallway.
d. Advise the client to eat a high-protein breakfast.
21. An older adolescent with a history of losing weight and feeling tired and irritable, has been
admitted to the hospital with a diagnosis of chronic glomerulonephritis. Which of the following
laboratory results would the nurse most likely see?
a. blood pH of 7 43
b. serum sodium of 140 mEa/L
c. BUN of 40 mg/dL
d. serum potassium of 4.1 mEg/L

22. A child was diagnosed with acute post-streptococcal glomerulonephritis and renal
insufficiency. Which laboratory result will the nurse expect to note in the child?
a. an elevated WBC count
c. negative protein in the urinalysis
b. negative RB in the urinalysis
d. an elevated BUN and serum creatinine

23. A client has been admitted to the hospital with a diagnosis of primary acute
glomerulonephritis. On assessment, the nurse first asks the client about a recent history of
a. bleeding ulcer
c. Tungal infection
b. hvpertension
d. streptococcal infection

24. A nurse is planning care for a client with acute glomerulonephritis. The nurse instructs the
nursing assistant to do which of the following in the care of the client?
a. Ambulate the client frequently.
b. Encourage a diet that is high in protein.
b. Monitor the temperature every 2 hours.
d. Remove the water pitcher from the bedside.

25 A nurse should make in which of the following dietary recommendations to a olient who has been
newly diagnosed with acute glomerulonephritis?
a restrict calories
b increase proteins
c. adequate carbohydrates
d restrict sodium

26. A school-aged client admitted to the hospital because of decreased urine output and periorbital
edera is diagnosed with glomerulonephritis. Which of the following interventions would receive the
highest priority?
a. Assessing vital signs every 4 hours
b Obtaining daily weight measurements.
c Obtaining serum electrolyte levels dailv.
d Monitoring intake and output every 12 hours.

27. A client has been diagnosed with acute glomerulonephritis. Which of the following
components should the nurse expect the child's urine to contain?
a blood
c. cystine crystals
b calcium casts
d. glucose

28. The nurse is taking frequent blood pressure readings on a child diagnosed with acute
glomerulonephritis. The parents ask the nurse why this is necessary. The nurse's reply should be based
on which of the following factors?
a Acute hypertension must be anticipated and identified.
b Hypotension leading to sudden shock can develop at any time.
c. Blood pressure fluctuations are a sign that the condition has become chronic.
d. Blood pressure fluctuations are a common adverse effect of antibiotic therapy.

29. When evaluating the urinalysis report of a child with acute glomerulonephritis, the nurse
would expect which of the following results?
a bacteriuria and hematuria
b. hematuria and proteinuria
c. bacteriuria and hematuria
d. proteinuria and bacteriuria

30. Which of the following statements by the nurse would be the best response to a mother who wants
to know the first indication that acute glomerulonephritis is improving?
a. Urine output will increase
c. Blood pressure increases.
b. Urine will be free of protein.
d. The child will have more energy.

31. When teaching a client how to prevent recurrences of acute glomerulonephritis, which
instruction should the nurse include?
a. "Strain all urine."
b. "Avoid physical activity."
c. "Monitor urine specific gravity every day."
d. "Seek early treatment for respiratory infection."

32. When developing the discharge plan for a client diagnosed with glomerulonephritis, which of the
following would the nurse expect to discuss?
a. Restricting dietary protein.
c. Restricting foods high in potassium.
b. Preventing respiratory infections
d. Monitoring pulse rate and rhythm.

33.- When preparing a care plan for a client with acute glomerulonephritis, the nurse should give top
priority to which intervention?
a monitoring fluid status
b. monitoring for hypokalemia
c. providing high-protein snacks
d. increasing client's sodium intake

34. A child with acute glomerulonephritis has a nursing diagnosis of Impaired Urinary
Elimination related to fluid retention and impaired glomerular filtration. The child should have. Which of
the following expected outcomes?
a exhibits no evidence of infection
b. engages in activities appropriate to capabilities
c demonstrates no periorbital, facial, or body edera
d. Maintains a fluid intake of more than 2.000 mL in 24 hours

35. an important nursing inievention ho suppor/the Wherapeunio management of the child with acute
glomerulonephritis would include which of the following?
a. measuring daily weight
b. increasing oral fluid intake
c. providing sodium supplements
d. monitoring client for signs of hypokalemia

36 The nurse is caring for an & year old following a routine tonsilleotomy, which finding should be
reported immediately?
a. Reluctance to swallow
b. Drooling of blood tinged saliva
c. An axillary temperature of 99F
d. Respiratory stridor

37. A 6 year old boy is returned to his room following a tonsillectomy. He remains sleepy from
anesthesia but is easily awakened. The nurse should place the child in which of the following positions?
a Prone position
b. Side lying position
c. Supine position
d. High fowler's position

38. The client had undergone total laryngectomy. He has permanent tracheostomy. Which nursing
intervention that need intervention during tracheal suctioning?
a. The nurse dons sterile gloves and uses sterile suction catheter.
b. The nurse administer 100% oxygen before and after suctioning
c. The nurse applies suction for 30 seconds at a time
d. The nurse applies suction during withdrawal of the suction catheter tip

39. The nurse teaches an adolescent who has had a tonsillectomy which of the following
teaching should be an emphasis?
a. avoid coughing and clearing the throat the first week postoperatively
b. do not eat or drink anything for the first 24 hours
c. if your stool is black for the first few days pot op, notify the doctor
d. avoid cold beverages to prevent irritation of the throat

40. A 49 year old client with cancer of the lung just had thoracentesis. The nurse would position the
client.
a. on the affected side
b. on the unaffected side
c. semi fowler's position
d on his back
41. The client who is admitted with thrombophlebitis has an order for heparin, the medication should be
administered using an:
a. Buretrol
b. Infusion controller
c. Intravenous filter
d. Three way stop cock

42. Which of the following diagnostic procedure should be done periodically if the client is taking
warfarin sodium?
a Stool specimen for occult blood
b. White blood cell count
© Blood glucose
d. Erythrocyte count

43. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the
following drugs reverses the effects of heparin?
a. Cyanocobalamine
b. Vitamin K
©. Protamine Sulfate
d. Streptokinase

44. The physician has prescribed Coumadin for a client with transient ischemic attack, which laboratory
test measures the therapeutic level of Coumadin?
a Prothrombin time
b Clot retraction time
c. Partial thromboplastin time
d Bleeding time

45. If a patient were to develop thromphlebitis at an intravenous infusions site which of the
following early findings should the nurse expect to observe?
a. Pallor and swelling
b Erythema and heat
c. Mottling and coolness
d. Leakage of fluid and numbness

46. The 10 year old is being treated for asthma. Before administering Theo-Dur, the nurse should check
the:
a. Urinary output
b. Blood pressure
c. Pulse
d. Temperature

47. The nurse is caring for a client with asthma, upon the morning arounds, the nurse finds as 02
saturation of 78%. Which of the following actions should the nurse take first?
a Notify the phvsician
b. Do nothing, this is normal 02 saturation for a patient.
c. Apply oxygen
d. Assess the patient's pulse

48. The nurse is caring for a client admitted with bronchitis, because of the possibility of
complete obstruction of the airway, which of the following should the nurse be prepared?
a. Intravenous access supplies
b. Intravenous fluid administration pump
c. Emergency intubation equipment
d. Supplemental oxygen

49. The physician has ordered intubation and mechanical ventilation for a client with periods of apnea
following a closed head injury. Arterial blood gases reveal a pH of 7.47. PCO2 of 28, and HCO3 of 23.
These findings indicates that the client has:
a. Respiratory acidosis
b. Respiratdry alkalosis
C. Metabolic acidosis
d. Metabolic alkalosis

50. A client with emphysema and cor pulmonale, which findings are characteristics of cor pulmonale?
a. Weight loss, increased RB and fever
b Hypoxia, shortness of breath and exertional fatigue
c. Rales, edema, and enlarged spleen
d. Edema of the lower extremities and distended neck veins

51. A client with emphysema has been receiving oxygen at 3L/min by nasal cannula, the nurse knows
that the goals of the client's oxygen therapy is achieved when the cleints PaO2 reading is
a 50-60mmlHg
b. 70-80mmHa
c. 80-90mmlg
d. 90-98mmlHg

52. A client was admitted to the hospital with chest pain and shortness of breath. Arterial blood gases
were pH 7.52, PCO2:27 , HCO3:22, these values indicates
a. Respiratory alkalosis
b. Respiratory acidosis
© Metabolic alkalosis
Metabolic acidosis

53. She The nurse enters the room of a olient with COPD the elient's Oxygen is running at 3 imm.
a. Check the doctor' order
b. Lower oxygen rate at 2L/min
C. Take the patient's vital signs
d. Put the client in fowler's position

54. Which of the following additional assessment data should immediately be gathered to determine
the status of a client with a respiratory rate of 4 breathes/min?
a. ABG and breath sounds
b. Level of consciousness and pulse oximetry value
c. Breath sounds and reflexes
d. Heart sounds and reflexes
55. A Client with emphysema is observed to have labored breathing and exhibits slow, shallow
respiration. This endangers him to develop:
a Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis

56. The nurse is obtaining a history on an 80 year old client, which statement made by the client might
indicate a potential for fluid and electrolvte imbalance?
a. I often use laxatives
b. My skin is always dry
C. I have always had a problem with dribbling urine
d. I have always liked to drink a lot of ice tea

57. A client is admitted to the acute care unit with the initial laboratory values reveal of serum sodium
170 meg/L, what behavior changes would be most common for his client?
a. Anger
c. Depression
b Mania
d. Psychosis

58. When assessing a client for risk for hyperphosphatemia, which piece of information is most
important for the nurse to obtain?
a. History of radiation treatment in the neck region
b. History of recent orthopedic surgery
c. History of minimal physical activity
d. History of client's food intake

59, The nurse is preparing to give an oral potassium supplement to a patient who is
hypokalemia, the nurse should give the medication:
a With 4 oz of juice
b. With water only
© With an empty stomach
d. Without diluting it.

60. Which selection would provide the most calcium for the client who has low level of calcium?
a Milk
b. Yogurt
c. Cheese
d. All of the choices

61. Which client is at risk for opportunistic disease such as pneumocystis pneumonia?
a A client with cancer who is being treated with chemotherapy
b. A client with type I diabetes
c. A client with thyroid disease
d. A client with Addison's disease
62. A allent with bacterial pneumonia is admited to the pediatrio unt. What would the nuise
a High fever
expect the admitting assessment to reveal?
b. Nonproductive cough
C. Rhinitis
d. Vomiting and diarrhea

63. Which of the following would be prioniv assessment data to gather from a client who has been
diagnosed with pneumonia? Select all that apply
1. Auscultation of breath sounds.
2.Auscultation of bowel sounds.
3. Presence of chest pain.
4. Presence of peripheral edema.
5 Color of nail beds.
a 1,2 3 and 5
b. 1, 2, and 4
c. 1. 3 and 5
d. 1, 4, and 5

64 Clients with chronic illnesses are more likely to get pneumonia when which of the following
situations is present?
a. Dehydration
b. Group living
c. Malnutrition
d Severe periodontal disease

65. An elderly client with pneumonia may appear with which of the following symptoms first?
a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and dyspnea
d. Pleuritic chest pain and cough

66. A 5 year old is a family contact to the client with tuberculosis. Isoniazid has been prescribe
for the client. The nurse is aware that the length of time that the medication will be taken is
c 6 months
a 3 months
d. 2 years
b. 1 year

67. The client is taking Rifampicin 600mg po daily to treat his tuberculosis, which action by the nurse
indicates understanding of the medications
a. Telling the client to take the medication before going to bed at night
b. Telling the client to take the medication if the night sweats occur
c. Telling the client that the medication will change the color of the urine
d. Telling the client that the medication will need to be taken with juice

68 A client is admitted to the hospital with a temperature of 99.8F complaints of blood tinged
hemoptysis, fatigue and night sweats. The client's symptoms are consistent with a diagnosis of
a. Pneumonia
b. Tuberculosis
c. Reaction to antiviral medication
d. Super infection due to low CD-4 count

69. A 45 year old homeless man is hospitalized with tuberculosis. The physician's orders
include isoniazid and pyridoxine. The patient asks why he is receiving pyridoxine. The nurse's response
should be based on the knowledge that pyridoxine is:
a Increases isoniazid absorption
b. Prevents the development of tolerance of isoniazid
c. Decreases the severity of isoniazid side effects
d. Prevents neuritis

70. Which of the following will the nurse interpret as positive mantoux test?
a Redness greater than 5mr
b Swelling greater than 7mm
c. Induration greater than 10mm
d. Exudates covering more than 12mm

71. the nursing is caring for a client diagnosis of hepatitis who is experiencing pruritus. Which would be
the most appropriate nursing intervention?
a. Suggest that the client take walthe shower two times per day.
b. Add baby oil to the client's bath water.
C. Apply powder to the client's skin
d. Suggest a hot water rinse after bathing.

72 While reviewing the chart of a elient with a history of a hepattis B, the nurse inds a
serologic marker which is ABS A : inte Nurse recognizes that the client has
a Chronic hepatitis B
b. Has recovered from hepatitis B infection
C. Has immunity to infection with hepatitis C
d. Has no chance of spreading the infection to others

73. A client is hospitalized with hepatitis A Which of the client's regular medication Is
contraindicated due fo the current illness?
a. Prilosec (omeprazole)
b. Premarin (conjugated estrogens)
d. Lipitor (atorvastatin)
b. Synthroid ( Levothyroxine)

74. The client that has a hepatitis has contracted the infection from contaminated food, what type of
hepatitis is this client most likely experiencing?
a Hepatitis A
c. Hepatitis C
d. Hepatitis D
b. Hepatitis B
75. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this
diagnosis?
a Elevated hemoglobin level
b. Elevated serum bilirubin level
c. Elevated blood urea nitrogen level
d. Decreased erythrocyte sedimentation rate

76. Jordin isra client with jaundice who is experiencing pruritus. Which nursing intervention would be
included in the care plan for the client?
a Administering vitamin K subcutaneously
b. Applying pressure when giving I.M. injections
c. Decreasing the client's dietary protein intake
d. Keeping the client's fingernails short and smooth

77. Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the
nurse understands the rationale for instituting skin care measures for the client?
a. Jaundice is associated with pressure ulcer formation."
b. "Jaundice impairs urea production, which produces pruritus."
C. Jaundice produces pruritus due to impaired bile acid excretion."
d. "Jaundice leads to decreased tissue perfusion and subsequent breakdown."

78. Which of the following will the nurse include in the care plan for a client hospitalized with viral
hepatitis?
a. Increase fluid intake to 3000 ml per day
b. Adequate bed rest
c. Bland diet
d. Administer antibiotics as ordered

79. A female client with hepatitis C develops liver failure and Gl hemorrhage. The blood
products that would most likely bring about hemostasis in the client are
a Whole blood and albumin.
b Platelets and packed red blood cells.
c. Fresh frozen plasma and whole blood.
d. Cryoprecipitate and fresh frozen plasma

80. Which phase of hepatitis would the nurse incur strict precautionary measures at?
c. Post-icteric
d. Pre-icteric
a Icteric
b. Non-icteric

81. Normal serum sodium concentration ranges from

a.115 - 125 mEg/L
b 125 - 135 mEq/L
c. 135 – 145 mEq/L
d. 145 - 155 mEal
82 Sodium levels are affected by the secretion of which of the following?
a progesterone and aldosterone
b. ECF and antidiuretic hormone
C antidiuretic hormone and aldosterone
d. FSH and progesterone

83. Which of the following intravenous solutions would be appropriate for a patient with severe
hyponatremia secondary to Syndrome of Inappropriate Anti-diuretic Hormone (SIADH)?
a hypotonic solution
b. hypertonic, solution
c. isotonic solution
d. normotonic solution

84. When assessing a patient for electrolvte balance, the nurse is aware that etiologies for
hyponatremia include
a. water gain
b vomiting
c diuretic therapy
d. all of the following

85. Nursing interventions for a patient with hyponatremia include:

a administering hypotonic IV fluids
b. increasing oral fluid intake
c. restricting fluid intake
d. avoiding sodium intake

86. When caring for a patient with hyponatremia, the nurse is careful to restrict:
a water
c. potassium
b sodium
d chloride

87. A patient with a diagnosis of bipolar disorder has been drinking copius amounts of water and voiding
frequently. The patient is experiencing muscle cramps, twitching, and is reporting dizziness. The nurse
checks lab work for:
a. EEG results.
b electrolytes, particularly the serum sodium.
c. complete blood count results, particularly the platelets.
d. urine analysis, particularly for the presence of white blood cells

88. When the serum sodium level is decreased, the adrenal glands send aldosterone to the kidneys to:
a. increase sodium reabsorption
b. decrease sodium reabsorption
c increase water reabsorption
d. decrease water reabsorption

89. Patients at high risk for hyponatremia include:

a patients receiving hypertonic feeding.
b. patients having hypokalemia.
c. patients on diuretic therapy.
d. patients who are dehydrated.

90. The nurse should administer hypertonic IV solutions with caution because these solutions
will force:
a water to leave the ECF
b. water to leave the ICF
c. cellular swelling
d. hydrostatic pressure to drop

91. The danger of having a serum sodium level of 115 mEg/L is

a renal response
b. cardiac effects
c. neurologic effects
d. blood gas changes

92. An 85-year-old patient with a feeding tube has been experiencing severe watery stool. The patient is
lethargic and has poor skin turgor a pulse of 120 bpm, and hyperactive reflexes. Nursing interventions
would include:
a administering sedatives.
b. measuring and recording intake and output and daily weights
c. applying wrist restraints to avoid displacement of the feeding tube
d. administering salt tablets and monitoring hypertonic parenteral solutions.

93. When assessing a patient for hypernatremia, the nurse would expect to find:
a thirst
b. hypoactive reflexes
c. moist mucous membranes
d. serum sodium level of 140 mEg/L

94. Which of the following IV solutions would the nurse administer for a patient with a serum
sodium level of 155 mEa/L?
a 3% normal saline solution
b. 5% normal saline solution
c. 0.9% normal saline solution
d. 0.45% normal saline solution

95 When caring for a patient with hypematremia, the nurse is careful to administer:
a water
b sodium
c potassium
d chloride

96. Which electrolyte imbalance will cause cellular shrinking?

a. hypernatremia
b. hyponatremia
c. hyperkalemia
d. hypokalemia

97. The major cation in the CF is:

a. potassium
b. sodium
c. phosphorous
d. magnesium

98. Which of the following electrolytes is lost as a result of vomiting?

a calcium
c. bicarbonate
b. potassium
d. plasma

99. Which may cause an intracellular shift of potassium?

a. hypoaldosteronism
b steroid deficiency
c. potassium-rich total parenteral nutrition
d. hypertonic glucose

100. Which of the following ECG test result is present in a client with a serum potassium level of
6.1 mEg/L?
a Inverted T wave
b. Shortened QRS complex
c. shortened ST segment
d. Tall T wave

101. Which of the following is a priority nursing diagnoses for a client with a hypokalemia?
a. Acute pain
c. Poor tissue perfusion
b. Impaired physical mobility
d. Impaired cardiac contractility

102. The physician has ordered IV replacement of potassium for a patient severe hypokaleria.
The nurse would administer this
a. by rapid bolus
b. diluted in 100 cc over 1 hour
c diluted in 10 cc over 10 minutes
d. IV push

103, Which of the following findings would the nurse expect to assess in a patient with
hypokalemia?
a anxiety
b. prolonged PR interval
© hyporeflexia
d. dysrhythmias

104. Which of the following symptoms is not associated with hypokalemia?

a muscle cramps
b. T waves on ECG
c. paresthesia
d. hyperreflexia

105. Oral potassium supplements should be administered:

a with meals
b. undiluted
c. on an empty stomach
d at bedtime

106. A patient is admitted with 1.000 mL of diarrhea per day for the last 3 days. An IV of 0.45% NaCI with
5% dextrose is infused. Which of the following nursing interventions is the most appropriate?
a. Assess the patient for signs of hyperkaleria.
b. Get an infusion controller from central supply.
c. Mix all antibiotics in 0.45% NaCI with 5% dextrose.
d. Check the patient's potassium level and contact the doctor for IV additive orders.

107. Mrs. Jones is rèceiving digoxin and Lasix daily. Today, Mrs. Jones complains of nausea,
and her apical pulse is 130 and irregular. Which of the following nursing interventions is the most
appropriate?
a. Identify the patient as high risk for hyperkalemia.
b. Remove the orange juice from the patient's tray.
c. Assess the patient for other signs of hypernatremia.
d, Hold the digoxin and check the patient's potassium level.

108. When assessing a patient for potassium deficits, the nurse is aware that normal serum
potassium level ranges from:
a 1.5 to 3.5 mEg/L
b. 2.5 to 4.5 mEg/L
C. 3.5 to 5.0 mEg/L
d. 4.0 to 6.5 mEg/L

109. A patient who is on Lasix therapy asks the nurse about potassium-rich foods, which of the following
foods would the nurse recommend?
a oranges
b. apples
c. pears
d. peaches

110. Which of the following interventions would the nurse undertake for a patient receiving IV
replacement of potassium?
a monitor pulse
b. monitor blood pressure
c. assess IV site
d. assess level of consciousness

111. The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first
to last, should the nurse complete the following tasks?
1. Position the client in a side-lying position.
2. Clean the skin with an antiseptic solution.
3. Verify the client has signed an informed consent.
4. Apply ice to the biopsy site.
a 1. 23 4
b. 3.2,1,4
C. 3,1,2,4
d. 4,1,2,3

112. A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because
the medication is causing nausea. The nurse should do which of the following? Select all that apply.
1. Suggest that the client use ginger when taking the medication
2. Ask the client what she thinks is causing the nausea.
3. Tell the client to use stool softeners to minimize constipation
4. Offer to administer the medication by an intramuscular injection
5. Suggest that the client take the iron with orange juice
a. 1. 2 and 4
b. 2 3 4 and 5
c. 1, 2 and 4
d 1. 2 and 5

113. A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now
"unable to concentrate at her card game" and "it seems harder and harder to finish her errands because
of exhaustion." Based on this information, the nurse should suggest that the client do which of the
following?
a. Take frequent naps.
b. Limit activities
C. Increase fluid intake.
d. Avoid contact with others.

114. A client is to have a transfusion of packed red blood cells from a designated donor. The
client asks if any diseases can be transmitted by this donor. The nurse should inform the client that
which of the following diseases can be transmitted by a designated donor? Select all thatapply.
1. Epstein-Barr virus,
2. Human immunodeficiency virus (HIV).
3. Cytomegalovirus (CMV).
4. Hepatitis A.
5. Malaria.
a. 1 2 and 3
b. 4 and 5
C. 2 and 4 only
d. 4 and 5 only

115. A client has been admitted with active rectal bleeding. He has been typed and cross-
matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints
when getting up to go to the bedside commode. The nurse noti-fies the health care provider, who
orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for
immediate transfusion?
a. A negative.
b. Bnegative
c. AB negative.
d. negative.

116. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to
follow after discharge. Which of the following foods should be included in the diet?
a. Eggs.
b. Lettuce.
c. Citrus fruits
d Cheese.

117. The nurse should instruct the client to eat which of the following foods to obtain the best
supply of vitamin B12?
a. Whole grains.
b. Green leafy vegetables.
c. Meats and dairy products.
d. Broccoli and brussels sprouts.

118. The nurse has just admitted a 35-year-old female client who has a serum vitamin B12
concentration of 800 pg/mL. Which of the following laboratory findings should cue the nurse to focus
the client history assessment on specific drug or alcohol use?
a.Total bilirubin. 0.3 mg/dL
b. Serum creatinine 0.5 mg/dL
c. Hemoglobin, 16 g/dL
d. Folate, 1.5 ng/mL

119. Which of the following lab values should the nurse report to the health care provider When the
client has anemia?
a. Schilling test result, elevated.
b. Intrinsic factor absent.
c. Sedimentation rate 16 mm per hour.
d. Red blood cells (RBCs) within
normal range.

120. The nurse devises a teaching plan for the client with aplastic anemia. Which of the
tollowing is the most important concept to teach for health promotion and maintenance?
a. Eat animal protein and dark green, leafy vegetables every day.
b. Avoid exposure to others with acute infections
c. Practice yoga and meditation to decrease stress and anxiety.
d. Get 8 hours of sleep at night and take naps during the day.

121. The nurse is assessing a 48-vear-old client with a history of smoking during a routine clinic visit. The
client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest.
Which of the following findings requires further evaluation?
a. Heart rate 57 bpm.
b Sp02 of 94% on room air.
c. Blood pressure 134/82.
d. Ankle brachial index of 0.65.

122. A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The
blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
a. IV fluid solution.
b. Pedal pulses.
©. Nasal cannula flow rate
d. Capillary refill.

123. An overweight client taking warfarin (Coumadin) has a nursing diagnosis of Ineffective tissue
perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do?
Select all that apply.
1. Apply lanolin or petroleum jelly to intact skin.
2. Encourage a reduced-calorie, reduced-fat diet.
3. Inspect the involved areas daily for new ulcerations.
4. Instruct the client to limit activities of daily living (ADLS)
5. Use an electric razor to shave.
a. 1 3 and 5
b. 2 and 4 only
c. 1. 2 3 and 5
d. 1 and 2 only

124. Peripheral blood flow is dependent on which of the following variables?

a Blood viscosity and diameter of vessels.
b. Diameter and resistance of vessels
c. Force of contraction of the heart and resistance of vessels.
d. Pressure differences in the arterial and venous systems and resistance

125. Blood pressure in the systemic circulation is highest in the

a. Arterioles
b. Capillaries
c. Aorta.
d. Venules

126. A common abnormal laboratory result associated with the development of peripheral
vascular disease (PVD) is:
a. High serum calcium level.
b. High serum lipid levels
© Low serum potassium level.
d. Low serum lipid levels.

127. The nurse is planning care for a client with a history of peripheral vascular disease who
has symptoms of claudication. Nursing care should be directed to avoiding which of the
following situations?
a. Oxygen demand by the muscle exceeds the supply.
b. Oxygen demand and supply of the working muscle are in balance
C. Oxygen supply exceeds the demand of the working muscle
d. Oxygen is absent.

128. Which of the following explains the influence of aging on the development of peripheral vascular
disease?
a Decreased resistance.
b. Increased resistance.
c. Decreased viscosity.
d. Increased viscosity.

129. The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when
she walks. The nurse bases a response on the knowledge that the main
characteristic of PVD is:
a. Decreased blood flow
b. Increased blood flow
c. Slow blood flow.
d. Thrombus formation.

130. The nurse is planning care for a client who is diagnosed with peripheral vascular disease
(PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact
that the client may have a low tolerance for exercise related to:
a. Decreased blood flow
b. Increased blood flow
c. Decreased pain
d. Increased blood viscosity

Situation 1: Elvira is admitted in the Medical ward due to paroxysmal chest pains.
131. Elvira suffered from chest pains upon ambulating from her bed to the CR. The nurse is giving
nitroglycerin and the pain has subsided. This type of chest pain is classified as
a. Prinzmetal angina
b. Stable angina
c. Unstable angina
d. Silent angina

132. Elvira is taking beta-blockers for her angina. Which of the following statements made by the patient
would warrant further teaching with the nurse?
a. "I will take this medication together with my beta2-agonist medications."
b. "This medication causes orthostatic hypotension so I need to gradually get up on bed upon waking up.
C. "Headache is a common side effect of this medication."
d. "I will not take this medication if I have a history of asthma attacks."
133. Calcium channel blockers are commonly given to patients with variant angina. Which of the
following medications should you anticipate in patients with variant angina? Select all that applies1.
Verapamil hydrochloride (Isoptin-SR)

1. Verapamil hydrochloride (Isoptin-SR)

2. Diltiazem (Cardizem)
3. Amlodepine (Norvasc)
4. Felodepine(Plendil)
5. Nicardipine (Cardene)
a. 1. 2. 3 and 4
b. 2 and 4 only
c. 1, 3 and 5 only
d 2 3 and 4

134. Elvira suddenly develops unstable angina receives routine applications of nitroglycerin ointment.
The nurse should delay the next dose if the client has:
a. Atrial fibrillation.
b. A systolic blood pressure below 90 mm Hg.
C. A headache
d. Skin redness at the current site.

135. Which of the following tests is used most often to diagnose angina?
a. Chest x-rav
b Echocardiogram
c. Cardiac catheterization
d. 12-lead electrocardiogram (ECG)

Situation 2 Shylove suddenly wakes up in the middle of sleep due to shortness of breath. She was rushed
in the emergency room. Tentative diagnosis is variant angina.

136. You are explaining to Shylove the mechanisms of variant angina. Which of the following statements
is correct regarding variant angina?
a. Angina occurs after physical activities and is relieved by rest or medications.
b. Angina that is unpredictable and is not relieved by rest or medications.
C. Angina that occurs at rest which is caused by vasospasm.
d. Angina that has no pain episodes but is evident via the ECG tracing.

137. Which of the following statements supports the mechanism of action of calcium channel blockers in
patients with variant angina
a. Calcium channel blockers decreases SA node automaticity.
b. Calcium channel blockers increases AV node conduction.
c. Calcium channel blockers increases the heart rate.
d. Calcium channel blockers creates a positive inotropic effect.

138. Which of the following statements, if made by the patient needs further teaching regarding variant
angina?
a. "I will have scheduled rest periods in between my activities to promote rest and relieve episodes of
pain."
b. "I will stay on bed at all times because pain will occur when ambulation happens."
C. "I will take my medications prior to doing activities of daily living
d. "I will report to the physician when my medications doesn't relieve my chest pains
even after taking it.”

139. For patients with angina pectoris, which of the following statements is true regardingangina
pectoris?
a. This condition is a constant occurrence of chest pain which is relieved with medications.
b. This condition is caused by constriction of the major arteries which deprives the body
from receiving adequate perfusion.
c. This condition is an episodic pain in the chest which is caused by inadequate supplies
of oxygen in the myocardium.
d. This condition is characterized by necrosis in the myocardium due to lack of oxygen
supply.

140. All of the following are manifestations of angina pectoris. Select all that applies.
1.Choking
2.Indigestion
3.Retrosternal pain
4.Positive Levine's sign
5.Twitching of the facial muscles
Answer ABC
a. 1. 2 and 3
b. 3 4 and 5
c 2 and 3 only
d. 4 and 5 only

Situation 3: Methodius is 31-year-old working as a corporate accountant. He was rushed in the

emergency department due to shortness of breath.

141. The emergency department has a shortage in sublingual nitroglycerin thus percutaneous
nitroglycerin administration is being chosen. Which among the following must be your site of choice
when administering percutaneous nitroglycerin?
a. Just above the bony surface
b. Directly under a large muscle
C. Non-hairy site
d. Near the apical site

142. As you administer the percutaneous nitroglycerine, you were asked by Methodius what is the
action of the medication. You are correct when you state which of the following statements?
a. It causes vasodilation, which results in the dilation of large veins which can lower down
the afterload and reduce the cardiac output.
b. It causes vasoconstriction, which results in the constriction of large veins which can
increase the afterload and increase cardiac output.
C. It causes vasodilation, which results in dilation of the large veins which can lower down the preload
and reduce cardiac output.
d. It causes vasoconstriction, which results in the constriction of the constriction of the
large veins which can increase the afterload and increase the cardiac output.

143. Methodius asked you how can the percutaneous nitroglycerin helps managing angina pectoris,
Which of the following statements is correct regarding nitroglycerin in angina pectoris?
a. It can decrease oxygen consumption; which can redistribute the flow of the coronary
arteries to the oxygen-deprived areas; relieves spasm of the coronary arteries and
improves general perfusion.
b. It can increase oxygen consumption; which can redistribute the flow of the coronary
arteries to the necrotic areas; relieves spasm of the coronary arteries and improves
perfusion to target organs.
c. It can decrease oxygen consumption; which can redistribute the flow of the coronary
arteries to the necrotic areas; relieves spasm of the coronary arteries and improves
perfusion to target organs.
d. It can increase oxygen consumption; which can redistribute the flow of the coronary
arteries to the oxygen-deprived areas; relieves spasm of the coronary arteries and
improves general perfusion.

144. Methodius has been diagnosed with stable angina. He is susceptible to paroxysms of chest pains
when heart needs extra oxygen. During which of the following situations does the heart need extra
oxygen levels?
a. Eating heavily in a buffet
b. Smoking cigarettes
C. Running around the track field
d. All the above mentioned is correct

145. What is the main goal of the drug therapy in angina pectoris?
a. Decrease heart rate and increase activation of RAAS.
b. Increase cardiac output and decrease body fluid volume
C. Improve myocardial perfusion and decrease metabolic demand in the myocardial cells
d. Increase myocardial contractility and decrease cardiac irritability

Situation 4: Ezra is rushed to the emergency department due to severe chest pains after playing
basketball.

146. Upon-doing baseline assessments, it is revealed that he has a family history of CAD Laboratory
findings include total cholesterol of 178 mg/dL; LDL of 120 mg/dL; HDL of 43 mg/dL; triglyceride of 148
ma/dL; and C-reactive protein of 4.2 ma/dL. You informed Ezra that he will be started to take
simvastatin and aspirin. Ezra asked you why is it he needs to take these medications. Which of the
following will be your best response?
a. “The lab results indicate severe hyperlipidemia and the medications will lower your LDL, along with
low-fat diet."
b. “The triglycerides are elevated and will not return to normal without these medications."
C. "The C-reactive protein is elevated indicating inflammation seen in the cardiovascular disease, which
can be lowered by the medications ordered."
d. "The medications are not indicated since your lab values are all normal."

147. During the previous few months, Ezra felt brief twinges of chest pain while playing basketball and
has had frequent episodes of indigestion. He comes to the hospital after experiencing severe anterior
chest pain in the middle of his basketball session. His evaluation confirms a diagnosis of stable angina
pectoris. After stabilization and treatment, the client is discharged from the hospital. At his follow-up
appointment, he is discouraged because he is experiencing pain with increasing frequency. He states
that he visits his friend, Rommel twice a week and now cannot walk up the second flight of steps to the
friend's apartment without pain. Which of the following measures that you could suggest would most
likely help the client prevent this problem?
a. Advise the patient to take nitroglycerin prior to climbing the stairs.
b. Visit his friend early in the day.
C. Rest for at least an hour before climbing the stairs
d. Lie down once he reaches his friend's apartment.

148. Ezra who experiences angina has been told to follow a low-cholesterol diet. Which of the following
meals should the nurse tell the client would be best on her low-cholesterol diet?
a. Hamburger, salad, and milkshake
b. Baked liver, green beans, and coffee
C. Spaghetti with tomato sauce, salad, and coffee
d. Fried chicken, green beans and skim milk

149. Ezra has a throbbing headache when nitroglycerin is taken for his angina. Which of the following
will be your instruction regarding his concern?
a. Acetaminophen or ibuprofen can be taken to relieve this common side effect.
b. Nitroglycerin should be avoided if the client is experiencing this serious adverse
reaction.
c. Take the nitroglycerin with few glasses of water will help reduce the problem.
d. Instruct the client to lie down after taking the medication to alleviate the headache

150. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct
the client to use the drug when chest pain occurs?
a. Take one tablet every 2 to 5 minutes until the pain stops.
b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10
minutes.
C. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets.
Call the physician if pain persists after three tablets.
d. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5
minutes later, call the physician.

Situation 5: You are caring for Shahane who is suffering from unstable angina

151. Which of the following symptoms should the nurse teach Shahane with unstable angina to report
immediately to her physician?
A. change in the pattern of pain
b. Pain during sexual activity
C. Pain during an argument with her boyfriend.
d. Pain during, or after an activity such as lawn-mowing

152. The physician refers Shahane with unstable angina for a cardiac catheterization. The nurse explains
to the client that this procedure is being used in this specific case to:
a. Open and dilate blocked coronary arteries
b. Assess the extent of arterial blockage
C. Bypass the obstructed vessels
d. Assess the functional adequacy of the valves and heart muscle

153. As an initial step in treating Shahane with angina, the physician prescribes nitroglycerin tablets, 03
mg given sublingually. This drug's principal effects are produced by:
a. Antispasmodic effects on the pericardium
b. Causing an increased myocardial oxygen demand
C. Vasodilation of peripheral vasculature
d. Improved conductivity in the myocardium

154. Frecy has angina and is being treated with nifepidine. What will be your teachings for this client?
a. Monitor blood pressure monthly
b. Perform daily weights
c. Inspect gums daily
d. Limit intake of green leafy vegetables

155. Frecy is being rushed to the emergency department due to chest pain and is being seen by the
physician Laboratory results reveals increase levels of myoglobin. An increase of mvoglobin would
indicate which of the following?
a. Cancer
b. Hypertension
C. Liver disease
d. Myocardial damage

Situation 6: Rommel has been rushed to the emergency department due to crushing pain in the chest
accompanied with shortness of breath.
156. Rommel has chest pain rated at 8 on a 10 point numerical pain score scale. The 12-lead
electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is
the highest priority for nursing management of this client at this time?
a. Monitor daily weights and urine output
B. Permit unrestricted visitation by the family and friends
c. Provide client education on medications and diet
d. Reduce pain and myocardial oxygen demand
157. Rommel has been diagnosed with anterior wall myocardial infarction. Upon assessment, the nurse
identifies a new systolic murmur at the apex. The nurse should first:
a. Assess for changes in vital signs
b. Draw an arterial blood gas
c. Evaluate heart sounds with the client leaning forward
d. Obtain a 12 lead electrocardiogram

158. Rommel has been receiving morphine sulfate for his severe chest pain. Which of the following
results are the intended effects of morphine with this client? Select all that applies.
1. Reduces myocardial oxygen consumption
2.Promotes reduction in respiratory rate
3 Prevents ventricular remodeling
4 Reduces blood pressure and heart rate
5 Reduces fear and anxiety
a 1,2, 3 and 4
b 1.4 and 5 onlv
c 1 3 and 5 only
d. 2 3 and 4
e. 1 only

159. Rommel has amlodipine as part of his treatment regimen. Which of the following assessment is of
greatest concern upon initiating the amlodipine drip?
a. Serum potassium of 3.5 mEq/L
b. Blood pressure of 80/60 mmHg
© ST elevation present on the ECG
d Heart rate of 66 beats per minute

160. should the nurse anticipate to observe?

Rommel suddenly develops cardiogenic shock, which of the following manifestation
a. Oliguria
b. Bradycardia
C. Elevated blood pressure
d. Fever

Situation 7: Selwyn is rushed in the emergency department due to decreased level of

consciousness and shortness of breath

161. Nurse Romabelle has completed an assessment on a client with a decreased cardiac output. Which
findings should receive the highest priority?
a. BP 110/60 mmHg; atrial fibrillation with heart rate of 87 beats per minute, bibasilar
crackles
b Confusion, urine output of 12 mL over the last 2 hours, orthopnea
C. SpO2 92% on 2 L nasal cannula oxygen, respirations of 20, +1 edema on the lower
extremities
d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise

162. Selwyn's heart rate decreases from 63 to 50 beats per minute upon assessment. What should be
the FIRST action of the nurse?
a. Administer atropine sulfate 05mg IV push
b. Auscultate for abnormal heart sounds
C. Prepare for transcutaneous pacing
d. Take the client's BP

163. Selwn suddenly develops atrial fibrillation. While auscultating the heart sounds, the nurse notes an
irregular heart rate and hearts an extra heart sound at the apex after the S2 cycle that remains constant
throughout the respiratory cycle. The nurse should document these findings as.
a. Heart rate irregular with S3
b. Heart rate irregular with S4
c. Heart rate irregular with mitral regurgitation
d. Heart rate irregular with mitral stenosis

164. Ashley is rushed in the emergency department with a complaint of crushing substernal chest pain
that radiates to this shoulder and left arm. The admitting diagnosis is acute myocardial infarction.
Immediate admission order include oxygen by nasal cannula at 4L/min, blood works, an chest
radiograph, a 12 Lead electrocardiogram, and 2 mg of morphine sulfate given 1.V. The nurse should
FIRST do which of the following orders?
A. Administer the morphine
B. Obtain a 12 Lead ECG
C. Obtain the blood work
D. Order the chest radiograph
165. Ashley suddenly develops cardiogenic shock. An arterial line has been inserted. Which of the
following orders should the nurse question?
a. Call for urine output less than 30 mL per hour for 2 consecutive hours
b. Metoprolol (Lopressor) 5mg IV push
c. Prepare for pulmonary artery catheter insertion
d. Titrate dobutamine (Dobutrex) to keep systolic BP > 100

Situation 8: Stephanie has been admitted in the Medical Ward due to severe chest pains.
Admitting diagnosis is acute coronary syndrome with ST elevation myocardial infarction.

166. Nurse Shaira is conducting health teachings to Stephanie. Stephanie asks regarding the origin of
pain of MI. What would be Shaira's best response?
a Left ventricular overload
b Impending circulatory collapse
C. Extracellular electrolyte imbalances
d Insufficient oxygen reaching the heart muscle

167. While taking care of Stephanie who has ACS with STEM, the nurse notes eight premature
ventricular contractions (PVCs) in one minute on the cardiac monitor. The client is receiving and IV
infusion of 5% dextrose in water and oxygen at 2L/min. The nurse FIRST course of action should be to
a. Increase the IV infusion rate
b. Notify the physician promptly
C. Increase oxygen concentration
d. Administer prescribed analgesic

168. Which of the following is an expected outcome for Stephanie on the second day of hospitalization
after a myocardial infarction (MI)? Stephanie:
a Has severe chest pain
b. Can identify risk factors for MI
c. Agrees to participate in cardiac rehabilitation program
d. Can perform personal self-care activities without pain

169. Stephanie is taking furosemide as her MI suddenly develops into left sided heart failure Which of
the following is an expected outcome when Stephanie receives IV administration of furosemide?
a Increased blood pressure
b Increased urine output
C. Decreased pain
d Decreased premature ventricular contractions

170. Which of the following reflects the principle on which a client's diet will most likely be based during
the acute phase of myocardial infarction?
a. Liquids as desired
b. Small, easily digested meals
c. Three reqular meals per day
d. Nothing by mouth

Situation 9: Kaye is rushed in the emergency department due to shortness of breath.

171. Kaye is being diagnosed with myocardial infarction. Alteplase recombinant or tissue plasminogen
activator, a thrombolytic enzyme, is administered during the first hours after the onset of myocardial
infarction in order to:
a. Control chest pain
b. Reduce coronary artery vasospasm
c. Control the arrythmias associated with MI
d. Revascularize the blocked coronary artery

172. After the administration of tissue plasminogen activator, the assessment priority should be which
of the following?
a. Observe the client for chest pain
b Monitor for fever
© Monitor the 12 lead ECG every 4 hours
d. Monitor breath sounds

173. Contraindications to the administration of tissue plasminogen activator (-PA) include which of the
following?
a. Age of greater than 60 years
b. History of cerebral hemorrhage
© History of heart failure
d Cigarette smoking

174. When monitoring Kaye who is receIving tissue plasminogen activator (1-PA), the nurse should have
resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the
following?
a. Cardiac arrhythmias
b. Hypertension
c. Seizure
d. Hypothermia
e.

175. Kaye suddenly develops epistaxis while under t-PA administration. Which of the following
medication should be anticipated to be administered by the nurse in this situation?
a Vitamin K
b. Protamine sulfate
C. Aminocaproic acid
d. Flumazenil

Situation 10: You are taking care of Nicole, who is admitted for shortness of breath and swelling of the
lower extremities.

176. Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for Nicole with
systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication
administration at 9 a.m., the nurse reviews the following lab tests: sodium of 140 mEq/L; potassium of
6.8 mEq/L; chloride of 101 mEq/L; BUN 18 mg/dL; creatinine 1.0 mg/dL. Which of the following should
the nurse do FIRST?
A Administer the medications
B. Call the physician
C. Withhold the captopril
D. Question the metoprolol use

177. Ciyde has chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%.
She is taking warfarin (Coumadin). The expected outcome of this drug is to:

a. Decrease circulatory overload

b. Improve the myocardial workload
c. Prevent thrombus formation
d. Regulate cardiac rhythm

178. Marian has a history of heart failure and has been taking several medications, including furosemide
(Lasix), digoxin (Lanoxin) and potassium chloride. She has nausea, blurred vision. headache, and
weakness. The nurse notes that the client is confused. The telemetry strip shows first degree
atrioventricular block. The nurse should assess the client for signs of which condition?
A. Hyperkalemia
B. Digoxin toxicity
C. Fluid deficit
D. Pulmonary edema

179. A nurse is assessing a client with heart failure. The nurse should assess the client based on which
compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
1. Ventricular hypertrophy
2. Dependent edema and anorexia
3. Coarse crackles and tachycardia
4.Hypotension and tachycardia
a 1 3 and 4
b. 2, 3 and 4
c 1 and 2 only
d. 2 only

180. Which of the following sets of conditions is an indication that Alyzza with a history of leftsided
heart failure is developing pulmonary edema?
a. Distended jugular veins and wheezing
b. Dependent edema and anorexia
c. Coarse crackles and tachycardia
d. Hypotension and tachycardia

Situation 11: Precia has been admitted in the cardiac unit due to exacerbation of heart failure.

181. Which of the following nursing diagnoses would be appropriate for Precia with heart failure? Select
all that apply.
1. Ineffective peripheral tissue perfusion related to decreased stroke volume
2. Activity intolerance related to impaired gas exchange and perfusion
3. Dyspnea related to pulmonary congestion and impaired gas exchange
4. Decreased cardiac output related to impaired cardiac filling
5. Impaired renal function related to decreased cardiac output
a. 2 3 and 4
b 3 and 5 only
C 1 , 2, 3 and 4
d. 2, 3 and 5

182. In which of the following positions should the nurse place Precia with heart failure?
a Low-fowler's position
b Lying on the right side
C High-fowler's position
d Lying on the back with the head lowered

183. The major goal of therapy for Precia with heart failure and pulmonary edema should be to:
a. Improve cardiac output
b Improve respiratory status
C Decrease peripheral edema
d. Enhance comfort

184. Precia has heart failure is receiving digoxin intravenously. The nurse should determine the
effectiveness of the drug by assessing which of the following?
a. Dilated coronary arteries
b. Increased myocardial contractility
c. Decreased cardiac arrhythmias
d. Decreased electrical activity in the heart

185. Nurse Jrenzo teaches Precia with heart failure to take oral furosemide in the morning. The primary
reason for this is to help:
a. Prevent electrolyte imbalances
b. Retard rapid drug absorption
c. Excrete excessive fluids accumulated during the night
d. Prevent sleep disturbances during the night

Situation 12: Margareth is being admitted in the emergency department due to shortness of breathand
cough for more than 2 weeks

186. Margareth has heart failure is prone to atrial fibrillation. During physical assessment, the nurse
should suspect atrial fibrillation when palpation of the radial pulse reveals:
a. Two irregular beats followed by one irregular beat
b. An irregular pulse rhythm
c. Pulse rate below 60
d. A weak, thready pulse

187. When teaching Margareth about complications of atrial fibrillation, the nurse should instruct the
client to avoid which of the following?
a. Stasis of blood in the atria
b. Increased cardiac output
C. Decreased pulse rate
d. Elevated blood pressure

188. Nurse Ezra should teach the Margareth that signs of digoxin toxicity include which of the following?
a. Rash over chest and back
b. Increased appetite
c. Visual disturbances such as seeing yellow spots
d. Elevated blood pressure

189. Nurse Ezra should be especially alert for signs and symptoms of digoxin toxicity if serum levels
indicate that the client has a:
a Low sodium level
b. High glucose level
C. High calcium level
d. Low potassium level

190. Which of the following foods should Nurse Ezra teach Margareth with heart failure to limitWhen
following a 2-g sodium diet?
a.Apples
b. Tomato juice
c. Whole wheat bread
d. Beef tenderloin

191. Vanile asked you about the different MODIFIABLE risk factors of CAD. You are correct when you
mentioned the following except:
a. Excessive levels of LDL
b. Sedentary lifestyle
c. Genetic predisposition
d. Cigarette smoking

192. Vanjie asked which among the lipids is healthy for the cardiovascular. You are correct when you
mention which of the following lipid?
a. Very low density lipoprotein
b. Low density lipoprotein
C. High density lipoprotein
d. Triglycerides

193. Nurse Jrenzo is making rounds in his area of assignment. Which of the following patients would
warrant report to the attending physician?
a. Ezra, who complains of severe chest pain even at rest, and is unrelieved with nitrates
b. Shvlove, who complains of chest pain upon ambulating, and is relieved upon sitting
down
c. Justin, who complains of chest pain even at rest but is relieved when taking medication
d. Methodius, who complains of chest pain, and is relieved upon taking the 3rd dose of
nitrates

194. Vanjle asked whether is it okay to do exercises when diagnosed with CAD. She also complained that
she feels tightness in her chest when she starts doing her exercise. What should be your best response
to Vanjie's concern?
a. "No, you are not allowed to do exercises as it can trigger pain episodes. You should stay in the
hospital for rehabilitation.
b. "Yes, you can exercise as long as you will take you nitrates 15 minutes prior to your
activity."
c. 'No, you are not allowed to do your exercises as long as pain is present. You need to
rest for the entire day.
d. “Yes, you can exercise if your lipid levels are within normal levels."

195. Vanjie is taking nitrates for her chest pains. Which of about the following statements made by her
needs additional teaching by the nurse?
a. "' Will store my nitrates on a dark colored container away from moisture."
b. “I Will take my nitrates when I experienced chest pains and will report to the emergency
department when it is unrelieved after taking the first dose."
C. '"' will cortinue to exercise vigorously for 75 minutes per week and will take nitrates
prior to exercise"
d. "' Will take my nitrate when I will experience chest pains and place the medication
under my tongue."

196. Which among the following is a medication used to lower down lipid and cholesterol levels? Select
all that applies.
a. Simvastatin (Crestor)
b. Atorvastatin (Lipitor)
C. Cholestyramine(Questran)
d. Clopidogrel (Plavix)
a. a, b, c and d
b b and c only
c a and d only
d. a b and c

Situation 13: You are the nurse assigned in the coronary unit taking care of patients with ischemicheart
disease.

197. Merylle is admitted in the Coronary unit due to shortness of breath and onset of chest pains. She is
undergoing atorvastatin as part of her treatment plan. She asks the purpose of the medication. You are
correct when you state which of the following statements
a. "This is an anti-lipemic used to lower down your lipid and cholesterol levels."
b. “This is an anti-platelet aggregator used to prevent thrombus formation."
c. "This is an ACE inhibitor used to lower down BP while excreting excess fluids in the
body."
d. "This is a bile sequestrant used to lower down cholesterol levels."

198. Merylle is also undergoing nitroglycerin therapy. When asked on the route of the medication,
which of the following is correct?
a Intramuscular
b. Intradermal
C. Subcutaneous
d. Sublinqual

199. Which of the following is an expected side effect of nitroglycerin?

a. Diarrhea
b. Tachycardia
C. Hypotension
d. Hypertension

200. The doctor is ordering low-molecular weight heparin as part of the treatment regimen for coronary
artery disease of Merylle. Which of the following medications should you anticipate to administer?
a. Clopidogrel (Plavix)
b. Tissue plasminogen activator t-PA (Alteplase)
C. Enoxaparin (Lovenox)
d. Warfarin (Coumadin)