Med Surg Success 3e A Q A Review Applying Critical... Chapter 3 Cardiac Disorders PDF

Cardiac Disorders
If you have knowledge, let others light their candles in it.

—Margaret Fuller
3
Heart disease is the leading cause of death in the United States. A nurse must have a thor-
ough knowledge of the signs/symptoms of cardiac disorders and of what to expect in assess-
ing and treating clients with heart-related problems.
KEYWORDS ABBREVIATIONS
Atelectasis Activities of daily living (ADLs)
Buccal Angiotensin-converting enzyme (ACE)
Cardiac tamponade Basal metabolic panel (BMP)
Crackles Blood pressure (BP)
Dyspnea Blood urea nitrogen (BUN)
Dysrhythmia B-type natriuretic peptide (BNP)
Eupnea Capillary refill time (CRT)
Exacerbation Cardiopulmonary resuscitation (CPR)
Intermittent claudication Chest x-ray (CXR)
Nocturia Chronic obstructive pulmonary disease (COPD)
Orthostatic hypotension Congestive heart failure (CHF)
Paresthesia Coronary artery disease (CAD)
Petechiae Dyspnea on exertion (DOE)
Pulse oximeter Electrocardiogram (ECG)
Pulsus paradoxus Endotracheal (ET)
Pyrosis Health-care provider (HCP)
Splinter hemorrhages Implantable cardioverter defibrillator (ICD)
Copyright © 2016. F. A. Davis Company. All rights reserved.
Telemetry International normalized ratio (INR)

Intravenous push (IVP)
Jugular vein distention (JVD)
Myocardial infarction (MI)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nothing by mouth (NPO)
Partial thromboplastin time (PTT)
Percutaneous transluminal coronary angioplasty
(PTCA)
Premature ventricular contraction (PVC)
Pulmonary embolus (PE)
Rule out (R/O)
Ventilation/perfusion (V/Q)
White blood cells (WBCs)
71
Colgrove, Kathryn Cadenhead. Med-Surg Success, 3e : A Q&A Review Applying Critical Thinking to Test Taking, F. A. Davis Company, 2016. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/galen-ebooks/detail.action?docID=4624901.
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72 M ed -S urg S uccess
PRACTICE QUESTIONS
Congestive Heart Failure 5. The nurse is assessing the client diagnosed with
congestive heart failure. Which signs/symptoms
1. The client is admitted to the telemetry unit would indicate that the medical treatment has
diagnosed with acute exacerbation of congestive been effective?
heart failure (CHF). Which signs/symptoms 1. The client’s peripheral pitting edema has gone
would the nurse expect to find when assessing this from 3+ to 4+.
client? 2. The client is able to take the radial pulse
1. Apical pulse rate of 110 and 4+ pitting edema accurately.
of feet. 3. The client is able to perform ADLs without
2. Thick white sputum and crackles that clear dyspnea.
with cough. 4. The client has minimal jugular vein distention.
3. The client sleeping with no pillow and eupnea. 6. The nurse is assessing the client diagnosed
4. Radial pulse rate of 90 and CRT less than three with congestive heart failure. Which laboratory
(3) seconds. data would indicate that the client is in severe
2. The nurse is developing a nursing care plan congestive heart failure?
for a client diagnosed with congestive heart 1. An elevated B-type natriuretic peptide (BNP).
failure. A nursing diagnosis of “decreased cardiac 2. An elevated creatine kinase (CK-MB).
output related to inability of the heart to pump 3. A positive D-dimer.
effectively” is written. Which short-term goal 4. A positive ventilation/perfusion (V/Q) scan.
would be best for the client? 7. The health-care provider has ordered an
1. The client will be able to ambulate in the hall angiotensin-converting enzyme (ACE) inhibitor
by date of discharge. for the client diagnosed with congestive heart
2. The client will have an audible S1 and S2 with failure. Which discharge instructions should the
no S3 heard by end of shift. nurse include?
3. The client will turn, cough, and deep breathe 1. Instruct the client to take a cough suppressant
every two (2) hours. if a cough develops.
4. The client will have a SaO2 reading of 98% by 2. Teach the client how to prevent orthostatic
day two (2) of care. hypotension.
3. The nurse is developing a discharge-teaching plan 3. Encourage the client to eat bananas to increase
for the client diagnosed with congestive heart potassium level.
failure. Which interventions should be included in 4. Explain the importance of taking the
the plan? Select all that apply. medication with food.
1. Notify the health-care provider of a weight 8. The nurse on the telemetry unit has just received
gain of more than one (1) pound in a week. the a.m. shift report. Which client should the
2. Teach the client how to count the radial pulse nurse assess first?
when taking digoxin, a cardiac glycoside. 1. The client diagnosed with myocardial
3. Instruct the client to remove the saltshaker infarction who has an audible S3 heart sound.
from the dinner table. 2. The client diagnosed with congestive heart
4. Encourage the client to monitor urine output failure who has 4+ sacral pitting edema.
for change in color to become dark. 3. The client diagnosed with pneumonia who has
5. Discuss the importance of taking the loop a pulse oximeter reading of 94%.
diuretic furosemide at bedtime. 4. The client with chronic renal failure who has
4. The nurse enters the room of the client diagnosed an elevated creatinine level.
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?
1. Sponge the client’s forehead.
2. Obtain a pulse oximetry reading.
3. Take the client’s vital signs.
4. Assist the client to a sitting position.

C hapter 3 C ardiac D isorders 73
9. The nurse and an unlicensed assistive personnel Angina/Myocardial Infarction

(UAP) are caring for four clients on a telemetry
unit. Which nursing task would be best for the 13. Which cardiac enzyme would the nurse expect
nurse to delegate to the UAP? to elevate first in a client diagnosed with a
1. Assist the client to go down to the smoking myocardial infarction (MI)?
area for a cigarette. 1. Creatine kinase (CK-MB).
2. Transport the client to the intensive care unit 2. Lactate dehydrogenase (LDH).
(ICU) via a stretcher. 3. Troponin.
3. Provide the client going home discharge- 4. White blood cells (WBCs).
teaching instructions.
4. Help position the client who is having a 14. Along with persistent, crushing chest pain, which
portable x-ray done. signs/symptoms would make the nurse suspect
that the client is experiencing a myocardial
10. The charge nurse is making shift assignments infarction?
for the medical floor. Which client should be 1. Midepigastric pain and pyrosis.
assigned to the most experienced registered 2. Diaphoresis and cool, clammy skin.
nurse? 3. Intermittent claudication and pallor.
1. The client diagnosed with congestive heart 4. Jugular vein distention and dependent edema.
failure who is being discharged in the
morning. 15. The client diagnosed with rule-out myocardial
2. The client who is having frequent incontinent infarction is experiencing chest pain while
liquid bowel movements and vomiting. walking to the bathroom. Which action should
3. The client with an apical pulse rate of 116, a the nurse implement first?
respiratory rate of 26, and a blood pressure of 1. Administer sublingual nitroglycerin.
94/62. 2. Obtain a STAT electrocardiogram (ECG).
4. The client who is complaining of chest pain 3. Have the client sit down immediately.
on inspiration and a nonproductive cough. 4. Assess the client’s vital signs.
11. The client diagnosed with congestive heart 16. The nurse is caring for a client diagnosed with a
failure is complaining of leg cramps at night. myocardial infarction who is experiencing chest
Which nursing interventions should be pain. Which interventions should the nurse
implemented? implement? Select all that apply.
1. Check the client for peripheral edema and 1. Administer morphine intramuscularly.
make sure the client takes a diuretic early in 2. Administer an aspirin orally.
the day. 3. Apply oxygen via a nasal cannula.
2. Monitor the client’s potassium level and assess 4. Place the client in a supine position.
the client’s intake of bananas and orange juice. 5. Administer nitroglycerin subcutaneously.
3. Determine if the client has gained weight and 17. The client who has had a myocardial infarction
instruct the client to keep the legs elevated. is admitted to the telemetry unit from intensive
4. Instruct the client to ambulate frequently and care. Which referral would be most appropriate
perform calf-muscle stretching exercises daily. for the client?
1. Social worker.
12. The nurse has written an outcome goal

“demonstrates tolerance for increased activity” 2. Physical therapy.
for a client diagnosed with congestive heart 3. Cardiac rehabilitation.
failure. Which intervention should the nurse 4. Occupational therapy.
implement to assist the client to achieve this 18. The client is one (1) day postoperative coronary
outcome? artery bypass surgery. The client complains of
1. Measure intake and output. chest pain. Which intervention should the nurse
2. Provide two (2)g sodium diet. implement first?
3. Weigh the client daily. 1. Medicate the client with intravenous
4. Plan for frequent rest periods. morphine.
2. Assess the client’s chest dressing and vital
signs.
3. Encourage the client to turn from side to side.
4. Check the client’s telemetry monitor.

19. The client diagnosed with a myocardial 23. The client diagnosed with a myocardial
infarction is six (6) hours post–right femoral infarction asks the nurse, “Why do I have to
percutaneous transluminal coronary angioplasty rest and take it easy? My chest doesn’t hurt
(PTCA), also known as balloon surgery. Which anymore.” Which statement would be the nurse’s
assessment data would require immediate best response?
intervention by the nurse? 1. “Your heart is damaged and needs about four
1. The client is keeping the affected extremity (4) to six (6) weeks to heal.”
straight. 2. “There is necrotic myocardial tissue that puts
2. The pressure dressing to the right femoral you at risk for dysrhythmias.”
area is intact. 3. “Your doctor has ordered bedrest. Therefore,
3. The client is complaining of numbness in the you must stay in the bed.”
right foot. 4. “Just because your chest doesn’t hurt anymore
4. The client’s right pedal pulse is 3+ and doesn’t mean you are out of danger.”
bounding.
24. The client has just returned from a cardiac
20. The intensive care department nurse is assessing catheterization. Which assessment data would
the client who is 12 hours post–myocardial warrant immediate intervention from the
infarction. The nurse assesses an S3 heart nurse?
sound. Which intervention should the nurse 1. The client’s BP is 110/70 and pulse is 90.
implement? 2. The client’s groin dressing is dry and intact.
1. Notify the health-care provider immediately. 3. The client refuses to keep the leg straight.
2. Elevate the head of the client’s bed. 4. The client denies any numbness and tingling.
3. Document this as a normal and expected
finding.
4. Administer morphine intravenously. Coronary Artery Disease
21. The nurse is administering a calcium channel 25. The male client is diagnosed with coronary
blocker to the client diagnosed with a artery disease (CAD) and is prescribed
myocardial infarction. Which assessment data sublingual nitroglycerin. Which statement
would cause the nurse to question administering indicates the client needs more teaching?
this medication? 1. “I should keep the tablets in the dark-colored
1. The client’s apical pulse is 64. bottle they came in.”
2. The client’s calcium level is elevated. 2. “If the tablets do not burn under my tongue,
3. The client’s telemetry shows occasional PVCs. they are not effective.”
4. The client’s blood pressure is 90/58. 3. “I should keep the bottle with me in my
22. The client diagnosed with a myocardial pocket at all times.”
infarction is on bedrest. The unlicensed assistive 4. “If my chest pain is not gone with one tablet, I
personnel (UAP) is encouraging the client to will go to the ER.”
move the legs. Which action should the nurse 26. The client with coronary artery disease asks
implement? the nurse, “Why do I get chest pain?” Which
1. Instruct the UAP to stop encouraging the leg statement would be the most appropriate
movements. response by the nurse?

2. Report this behavior to the charge nurse as 1. “Chest pain is caused by decreased oxygen to
soon as possible. the heart muscle.”
3. Praise the UAP for encouraging the client to 2. “There is ischemia to the myocardium as a
move the legs. result of hypoxemia.”
4. Take no action concerning the UAP’s 3. “The heart muscle is unable to pump
behavior. effectively to perfuse the body.”
4. “Chest pain occurs when the lungs cannot
adequately oxygenate the blood.”

27. The client is scheduled for a right femoral 33. The nurse is discussing angina with a client
cardiac catheterization. Which nursing who is diagnosed with coronary artery disease.
intervention should the nurse implement after Which action should the client take first when
the procedure? experiencing angina?
1. Perform passive range-of-motion exercises. 1. Put a nitroglycerin tablet under the tongue.
2. Assess the client’s neurovascular status. 2. Stop the activity immediately and rest.
3. Keep the client in high Fowler’s position. 3. Document when and what activity caused
4. Assess the gag reflex prior to feeding the angina.
client. 4. Notify the health-care provider immediately.
28. The nurse is preparing to administer a beta 34. The client with coronary artery disease is
blocker to the client diagnosed with coronary prescribed a Holter monitor. Which intervention
artery disease. Which assessment data would should the nurse implement?
cause the nurse to question administering the 1. Instruct the client to keep a diary of activity,
medication? especially when having chest pain.
1. The client has a BP of 110/70. 2. Discuss the need to remove the Holter
2. The client has an apical pulse of 56. monitor during a.m. care and showering.
3. The client is complaining of a headache. 3. Explain that all medications should be
4. The client’s potassium level is 4.5 mEq/L. withheld while wearing a Holter monitor.
4. Teach the client the importance of decreasing
29. Which intervention should the nurse implement
activity while wearing the monitor.
when administering a loop diuretic to a client
diagnosed with coronary artery disease? 35. Which statement by the client diagnosed with
1. Assess the client’s radial pulse. coronary artery disease indicates that the client
2. Assess the client’s serum potassium level. understands the discharge teaching concerning
3. Assess the client’s glucometer reading. diet?
4. Assess the client’s pulse oximeter reading. 1. “I will not eat more than six (6) eggs a week.”
2. “I should bake or grill any meats I eat.”
30. Which client teaching should the nurse
3. “I will drink eight (8) ounces of whole milk a
implement for the client diagnosed with
day.”
coronary artery disease? Select all that apply.
4. “I should not eat any type of pork products.”
1. Encourage a low-fat, low-cholesterol diet.
2. Instruct the client to walk 30 minutes a day. 36. The charge nurse is making assignments for
3. Decrease the salt intake to two (2) g a day. clients on a cardiac unit. Which client should the
4. Refer to a counselor for stress reduction charge nurse assign to a new graduate nurse?
techniques. 1. The 44-year-old client diagnosed with a
5. Teach the client to increase fiber in the diet. myocardial infarction.
2. The 65-year-old client admitted with unstable
31. The elderly client has coronary artery disease.
angina.
Which question should the nurse ask the client
3. The 75-year-old client scheduled for a cardiac
during the client teaching?
catheterization.
1. “Do you have a daily bowel movement?”
4. The 50-year-old client complaining of chest
2. “Do you get yearly chest x-rays (CXRs)?”
pain.
3. “Are you sexually active?”
4. “Have you had any weight change?”
32. The nurse is discussing the importance of Valvular Heart Disease
exercise with the client diagnosed with coronary
artery disease. Which intervention should the 37. A client is being seen in the clinic to rule out
nurse implement? (R/O) mitral valve stenosis. Which assessment
1. Perform isometric exercises daily. data would be most significant?
2. Walk for 15 minutes three (3) times a week. 1. The client complains of shortness of breath
3. Do not walk outside if it is less than 40˚F. when walking.
4. Wear open-toed shoes when ambulating. 2. The client has jugular vein distention and 3+
pedal edema.
3. The client complains of chest pain after eating
a large meal.
4. The client’s liver is enlarged and the abdomen
is edematous.

38. Which assessment data would the nurse expect 44. The client who has just had a percutaneous
to auscultate in the client diagnosed with mitral balloon valvuloplasty is in the recovery room.
valve insufficiency? Which intervention should the Post Anesthesia
1. A loud S1, S2 split, and a mitral opening snap. Care Unit nurse implement?
2. A holosystolic murmur heard best at the 1. Assess the client’s chest tube output.
cardiac apex. 2. Monitor the client’s chest dressing.
3. A midsystolic ejection click or murmur heard 3. Evaluate the client’s endotracheal (ET) lip
at the base. line.
4. A high-pitched sound heard at the third left 4. Keep the client’s affected leg straight.
intercostal space.
45. The client with a mechanical valve replacement
39. The client has just received a mechanical valve asks the nurse, “Why do I have to take
replacement. Which behavior by the client antibiotics before getting my teeth cleaned?”
indicates the client needs more teaching? Which response by the nurse is most
1. The client takes prophylactic antibiotics. appropriate?
2. The client uses a soft-bristle toothbrush. 1. “You are at risk of developing an infection in
3. The client takes an enteric-coated aspirin your heart.”
daily. 2. “Your teeth will not bleed as much if you have
4. The client alternates rest with activity. antibiotics.”
3. “This procedure may cause your valve to
40. The nurse is teaching a class on valve
malfunction.”
replacements. Which statement identifies a
4. “Antibiotics will prevent vegetative growth on
disadvantage of having a biological tissue valve
your valves.”
replacement?
1. The client must take lifetime anticoagulant 46. The client had open-heart surgery to replace
therapy. the mitral valve. Which intervention should the
2. The client’s infections are easier to treat. intensive care unit nurse implement?
3. There is a low incidence of thromboembolism. 1. Restrict the client’s fluids as ordered.
4. The valve has to be replaced frequently. 2. Keep the client in the supine position.
3. Maintain oxygen saturation at 90%.
41. The nurse is preparing to administer warfarin
4. Monitor the total parenteral nutrition.
(Coumadin), an oral anticoagulant, to a client
with a mechanical valve replacement. The 47. Which client would the nurse suspect of having
client’s INR is 2.7. Which action should the a mitral valve prolapse?
nurse implement? 1. A 60-year-old female with congestive heart
1. Administer the medication as ordered. failure.
2. Prepare to administer vitamin K 2. A 23-year-old male with Marfan’s
(AquaMephyton). syndrome.
3. Hold the medication and notify the HCP. 3. An 80-year-old male with atrial fibrillation.
4. Assess the client for abnormal bleeding. 4. A 33-year-old female with Down
syndrome.
42. Which signs/symptoms should the nurse assess
in any client who has a long-term valvular heart 48. The charge nurse is making shift assignments.
disease? Select all that apply. Which client would be most appropriate for the
1. Paroxysmal nocturnal dyspnea. charge nurse to assign to a new graduate who
2. Orthopnea. just completed orientation to the medical floor?
3. Cough. 1. The client admitted for diagnostic tests to
4. Pericardial friction rub. rule out valvular heart disease.
5. Pulsus paradoxus. 2. The client three (3) days post–myocardial
infarction being discharged tomorrow.
43. The client is being evaluated for valvular heart
3. The client exhibiting supraventricular
disease. Which information would be most
tachycardia (SVT) on telemetry.
significant?
4. The client diagnosed with atrial fibrillation
1. The client has a history of coronary artery
who has an INR of five (5).
disease.
2. There is a family history of valvular heart
disease.
3. The client has a history of smoking for 10 years.
4. The client has a history of rheumatic heart
disease.

Dysrhythmias and Conduction Problems 54. The client has chronic atrial fibrillation. Which
discharge teaching should the nurse discuss with
49. The telemetry nurse is unable to read the the client?
telemetry monitor at the nurse’s station. 1. Instruct the client to use a soft-bristle
Which intervention should the telemetry nurse toothbrush.
implement first? 2. Discuss the importance of getting a monthly
1. Go to the client’s room to check the client. partial thromboplastin time (PTT).
2. Instruct the primary nurse to assess the client. 3. Teach the client about signs of pacemaker
3. Contact the client on the client call system. malfunction.
4. Request the nursing assistant to take the crash 4. Explain to the client the procedure for
cart to the client’s room. synchronized cardioversion.
50. The client shows ventricular fibrillation on the 55. The client is exhibiting ventricular tachycardia.
telemetry at the nurse’s station. Which action Which intervention should the nurse implement
should the telemetry nurse implement first? first?
1. Administer epinephrine IVP. 1. Administer amiodarone , an antidysrhythmic,
2. Prepare to defibrillate the client. IVP.
3. Call a STAT code. 2. Prepare to defibrillate the client.
4. Start cardiopulmonary resuscitation (CPR). 3. Assess the client’s apical pulse and blood
pressure.
51. The client is experiencing multifocal premature 4. Start basic cardiopulmonary resuscitation.
ventricular contractions. Which antidysrhythmic
medication would the nurse expect the health- 56. The client is in complete heart block. Which
care provider to order for this client? intervention should the nurse implement first?
1. Amiodarone. 1. Prepare to insert a pacemaker.
2. Atropine. 2. Administer atropine, an antidysrhythmic.
3. Digoxin. 3. Obtain a STAT electrocardiogram (ECG).
4. Adenosine. 4. Notify the health-care provider.
52. The client is exhibiting sinus bradycardia, is 57. The client is in ventricular fibrillation. Which
complaining of syncope and weakness, and has interventions should the nurse implement?
a BP of 98/60. Which collaborative treatment Select all that apply.
should the nurse anticipate being implemented? 1. Start cardiopulmonary resuscitation.
1. Administer a thrombolytic medication. 2. Prepare to administer the antidysrhythmic
2. Assess the client’s cardiovascular status. adenosine IVP.
3. Prepare for insertion of a pacemaker. 3. Prepare to defibrillate the client.
4. Obtain a permit for synchronized 4. Bring the crash cart to the bedside.
cardioversion. 5. Prepare to administer the antidysrhythmic
amiodarone IVP.
when defibrillating a client who is in ventricular 58. The client who is one (1) day postoperative
fibrillation? coronary artery bypass surgery is exhibiting
1. Defibrillate the client at 50, 100, and sinus tachycardia. Which intervention should the
200 joules. nurse implement?

2. Do not remove the oxygen source during 1. Assess the apical heart rate for one (1) full
defibrillation. minute.
3. Place petroleum jelly on the defibrillator pads. 2. Notify the client’s cardiac surgeon.
4. Shout “all clear” prior to defibrillating the 3. Prepare the client for synchronized
client. cardioversion.
4. 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?
1. Document this as normal sinus rhythm.
2. Request a 12-lead electrocardiogram.
3. Prepare to administer the cardiotonic
digoxin PO.
4. Assess the client’s cardiac enzymes.

60. Which client problem has priority for the client 66. The client diagnosed with pericarditis is
with a cardiac dysrhythmia? experiencing cardiac tamponade. Which
1. Alteration in comfort. collaborative intervention should the nurse
2. Decreased cardiac output. anticipate for this client?
3. Impaired gas exchange. 1. Prepare for a pericardiocentesis.
4. Activity intolerance. 2. Request STAT cardiac enzymes.
3. Perform a 12-lead electrocardiogram.
4. Assess the client’s heart and lung sounds.
Inflammatory Cardiac Disorders
67. The female client is diagnosed with rheumatic
61. The client is diagnosed with pericarditis. Which fever and prescribed penicillin, an antibiotic.
are the most common signs/symptoms the Which statement indicates the client needs
nurse would expect to find when assessing the more teaching concerning the discharge
client? teaching?
1. Pulsus paradoxus. 1. “I must take all the prescribed antibiotics.”
2. Complaints of fatigue and arthralgias. 2. “I may get a vaginal yeast infection with
3. Petechiae and splinter hemorrhages. penicillin.”
4. Increased chest pain with inspiration. 3. “I will have no problems as long as I take my
medication.”
62. The client is diagnosed with acute pericarditis. 4. “My throat culture was positive for a
Which sign/symptom warrants immediate streptococcal infection.”
attention by the nurse?
1. Muffled heart sounds. 68. Which potential complication should the nurse
2. Nondistended jugular veins. assess for in the client with infective endocarditis
3. Bounding peripheral pulses. who has embolization of vegetative lesions from
4. Pericardial friction rub. the mitral valve?
1. Pulmonary embolus (PE).
63. The client is admitted to the medical unit to rule 2. Cerebrovascular accident.
out carditis. Which question should the nurse 3. Hemoptysis.
ask the client during the admission interview to 4. Deep vein thrombosis.
support this diagnosis?
1. “Have you had a sore throat in the last 69. Which nursing diagnosis would be priority for
month?” the client diagnosed with myocarditis?
2. “Did you have rheumatic fever as a child?” 1. Anxiety related to possible long-term
3. “Do you have a family history of carditis?” complications.
4. “What over-the-counter (OTC) medications 2. High risk for injury related to antibiotic
do you take?” therapy.
3. Increased cardiac output related to valve
64. The client with pericarditis is prescribed a regurgitation.
nonsteroidal anti-inflammatory drug (NSAID). 4. Activity intolerance related to impaired
Which teaching instruction should the nurse cardiac muscle function.
discuss with the client?
70. The client diagnosed with pericarditis is being
1. Explain the importance of tapering off the

medication. discharged home. Which intervention should the
2. Discuss that the medication will make the nurse include in the discharge teaching?
client drowsy. 1. Be sure to allow for uninterrupted rest and
3. Instruct the client to take the medication with sleep.
food. 2. Refer the client to outpatient occupational
4. Tell the client to take the medication when therapy.
the pain level is around “8.” 3. Maintain oxygen via nasal cannula at two
(2) L/min.
65. The client diagnosed with pericarditis 4. Discuss upcoming valve replacement surgery.
is complaining of increased pain. Which
intervention should the nurse implement first?
1. Administer oxygen via nasal cannula.
2. Evaluate the client’s urinary output.
3. Assess the client for cardiac complications.
4. Encourage the client to use the incentive
spirometer.

71. The client has just had a pericardiocentesis. 72. The client with infective endocarditis is admitted
Which interventions should the nurse to the medical department. Which health-care
implement? Select all that apply. provider’s order should be implemented first?
1. Monitor vital signs every 15 minutes for the 1. Administer intravenous antibiotic.
first hour. 2. Obtain blood cultures times two (2).
2. Assess the client’s heart and lung sounds. 3. Schedule an echocardiogram.
3. Record the amount of fluid removed as 4. Encourage bedrest with bathroom privileges.
output.
4. Evaluate the client’s cardiac rhythm.
5. Keep the client in the supine position.
CONCEPTS
The concepts covered in this chapter focus on the cardiac-related areas of nursing; perfusion-related problems of
myocardial infarction, dysrhythmias, heart failure, and hypertension; and the interrelated concepts of the nursing
process and critical thinking. The concept of nursing process is displayed throughout the questions. The concept
of critical thinking is presented in any prioritizing or “first” question.
73. The nurse enters the client’s room and notes 5. Determine if the client is on an antiplatelet or
an unconscious client with an absence of anticoagulant medication.
respirations and no pulse or blood pressure. 6. Assess the client’s neurological status every
The concept of perfusion is identified by the shift and prn.
nurse. Which should the nurse implement
76. The nurse identifies the concept of perfusion for
first?
a client diagnosed with congestive heart failure.
1. Notify the health care provider.
Which assessment data support this concept?
2. Call a rapid response team (RRT).
1. The client has a large abdomen and a positive
3. Determine the telemetry monitor reading.
tympanic wave.
4. Push the Code Blue button.
2. The client has paroxysmal nocturnal dyspnea.
74. The 45-year-old male client diagnosed with 3. The client has 2+ glucose in the urine.
essential hypertension has decided not to take 4. The client has a comorbid condition of
his medications. The client’s BP is 178/94, myocardial infarction.
indicating a perfusion issue. Which question
77. The nurse is caring for a client diagnosed with
should the nurse ask the client first?
coronary artery disease (CAD). Which should
1. “Do you have the money to buy your
the nurse teach the client prior to discharge?
medication?”
1. Carry your nitroglycerin tablets in a brown
2. “Does the medication give unwanted side
bottle.
effects?”
2. Swallow a nitroglycerin tablet at the first sign
3. “Did you quit taking the medications because
of angina.
you don’t feel bad?”
3. If one nitroglycerin tablet does not work in 10

4. “Can you tell me why you stopped taking the
minutes, take another.
medication?”
4. Nitroglycerin tablets have a fruity odor if they
75. The nurse identifies the concept of altered tissue are potent.
perfusion related to a client admitted with atrial
78. The nurse is caring for a client who suddenly
fibrillation. Which interventions should the
complains of crushing substernal chest pain
nurse implement? Select all that apply.
while ambulating in the hall. Which nursing
1. Monitor the client’s blood pressure and apical
action should the nurse implement first?
rate every four (4) hours.
1. Call a Code Blue.
2. Place the client on intake and output every
2. Assess the telemetry reading.
shift.
3. Take the client’s apical pulse.
3. Require the client to sleep with the head of
4. Have the client sit down.
the bed elevated.
4. Teach the patient to perform Buerger Allen
exercises daily.

79. The client’s telemetry reading is below.

Which should the nurse implement?
1. Take the client’s apical pulse and blood pressure.
2. Prepare to administer amiodarone IVPB.
3. Continue to monitor.
4. Place oxygen on the client via a nasal cannula.
80. The nurse is functioning in the role of 83. The nurse is admitting a client diagnosed with
medication nurse during a code. Which should coronary artery disease (CAD) and angina.
the nurse implement when administering Which concept is priority?
amiodarone for ventricular tachycardia? 1. Sleep, rest, activity.
1. Mix the medication in 100 mL of fluid and 2. Comfort.
administer rapidly. 3. Oxygenation.
2. Push the amiodarone directly into the nearest 4. Perfusion.
IV port and raise the arm.
84. The home health nurse is assigned a client
3. Question the physician’s order because it is
diagnosed with heart failure. Which should the
not ACLS recommended.
nurse implement? Select all that apply.
4. Administer via an IV pump based on
1. Request a dietary consult for a sodium-
mg/kg/min.
restricted diet.
81. The client diagnosed with an ST elevation 2. Instruct the client to elevate the feet during
myocardial infarction (STEMI) has developed the day.
2+ edema bilaterally of the lower extremities 3. Teach the client to weigh every morning
and has crackles in all lung fields. Which should wearing the same type of clothing.
the nurse implement first? 4. Assess for edema in dependent areas of the
1. Notify the health care provider (HCP). body.
2. Assess what the client ate at the last meal. 5. Encourage the client to drink at least
3. Request a STAT 12 lead electrocardiogram. 3,000 mL of fluid per day.
4. Administer furosemide IVP. 6. Have the client repeat back instructions to the
nurse.
82. The nurse is administering morning medications
to clients on a telemetry unit. Which medication
would the nurse question?
1. Furosemide IVP to a client with a potassium

level of 3.6 mEq/L.
2. Digoxin orally to a client diagnosed with
rapid atrial fibrillation.
3. Enalapril orally to a client whose BP is 86/64
and apical pulse is 65.
4. Morphine IVP to a client complaining of
chest pain and who is diaphoretic.

85. The telemetry monitor tech notifies the nurse of the strip shown below.
Which should the nurse implement first?
1. Instruct the unlicensed assistive personnel (UAP) to check the client.
2. Go to the client’s room and assess the client personally.
3. Have the monitor tech check the client using a different lead.
4. Call for the Code Blue team and perform cardiopulmonary resuscitation.
86. The nurse is working with a group of new 89. The nurse is administering morning
graduates on a medical-surgical unit. Which medications. Which medication should be
should the nurse explain about completing first administered first?
morning rounds on clients? 1. The cardiac glycoside medication, digoxin, to
1. Perform a “down and dirty” assessment on a client diagnosed with heart failure and who
each client soon after receiving report. has 2+ edema of the feet.
2. Determine which client should have a bath 2. The sliding scale insulin to a client with a
and inform the unlicensed assistive personnel. fasting blood glucose of 345 mg/dL who is
3. Give all the clients a wet wash to wash the demanding breakfast.
face and a toothbrush and toothpaste. 3. The loop diuretic, furosemide, to a client with
4. Pick up any paper on the floor and get the room a 24-hour intake of 986 mL and an output of
ready for morning physician rounds. 1,400 mL.
4. The ARB medication to a client whose blood
87. The nurse has received shift report. Which
pressure was reported by the unlicensed
client should the nurse assess first?
assistive personnel as 142/76.
1. The client diagnosed with coronary artery
disease complaining of severe indigestion. 90. The nurse identifies the concept of tissue
2. The client diagnosed with congestive heart perfusion as a client problem. Which is an
failure who has 3+ pitting edema. antecedent of tissue perfusion?
3. The client diagnosed with atrial fibrillation 1. The client has a history of coronary artery
whose apical rate is 110 and irregular. disease (CAD).
4. The client diagnosed with sinus bradycardia 2. The client has a history of diabetes insipidus
who is complaining of being constipated. (DI).

3. The client has a history of chronic obstructive
88. The client diagnosed with a myocardial
pulmonary disease (COPD).
infarction (MI) is being discharged. Which
4. The client has a history of multiple fractures
discharge instruction(s) should the nurse teach
from a motor-vehicle accident.
the client?
1. Call the health care provider (HCP) if any
chest pain happens.
2. Discuss when the client can resume sexual
activity.
3. Explain the pharmacology of nitroglycerin
tablets.
4. Encourage the client to sleep with the head of
the bed elevated.

PRACTICE QUESTIONS
ANSWERS AND RATIONALES
Congestive Heart Failure taker should look for an answer that addresses
the ability of the heart to pump blood.
1. 1. The client with CHF would exhibit tachy- Content – Medical: Integrated Nursing Process –
cardia (apical pulse rate of 110), dependent Planning: Client Needs – Safe Effective Care Environment,
edema, fatigue, third heart sounds, lung Management of Care: Cognitive Level – Synthesis:
congestion, and change in mental status. Concept – Perfusion.
2. The client with CHF usually has pink frothy 3. 1. The client should notify the HCP of weight
sputum and crackles that do not clear with gain of more than two (2) or three (3) pounds
coughing. in one (1) day.
3. The client with CHF would report sleeping 2. The client should not take digoxin if the
on at least two pillows, if not sleeping in an radial pulse is less than 60.
upright position, and labored breathing, not 3. The client should be on a low-sodium diet
eupnea, which means normal breathing. to prevent water retention.
4. In a client diagnosed with heart failure, the 4. The color of the urine should not change to a
apical pulse, not the radial pulse, is the best dark color; if anything, it might become lighter
place to assess the cardiac status. and the amount will increase with diuretics.
TEST-TAKING HINT: In option “3,” the word 5. Instruct the client to take the diuretic in the
“no” is an absolute term and, usually, ab- morning to prevent nocturia.
solutes, such as “no,” “never,” “always,” and TEST-TAKING HINT: This is an alternative-type
“only,” are incorrect because there is no room question—in this case, “Select all that apply.” If
for any other possible answer. If the test taker the test taker missed this statement, it is pos-
is looking for abnormal data, then the test sible to jump at the first correct answer. This is
taker should exclude the options that have one reason that it is imperative to read all op-
normal values in them, such as eupnea, pulse tions before deciding on the correct one(s). This
rate of 90, and capillary refill time (CRT) less could be a clue to reread the question for clarity.
than three (3) seconds. Another hint that this is an alternative question
Content – Medical: Integrated Nursing Process – is the number of options. The other questions
Assessment: Client Needs – Physiological Integrity, have four potential answers; this one has five.
Physiological Adaptation: Cognitive Level – Analysis: Numbers in an answer option are always im-
Concept – Perfusion. portant. Is one (1) pound enough to indicate a
2. 1. Ambulating in the hall by day of discharge problem that should be brought to the attention
would be a more appropriate goal for an of the health-care provider?
activity-intolerance nursing diagnosis. Content – Medical: Integrated Nursing Process – Planning:
2. Audible S1 and S2 sounds are normal for a Client Needs – Physiological Integrity, Physiological Adaptation:
Cognitive Level – Synthesis: Concept – Nursing Roles.
heart with adequate output. An audible S3

sound might indicate left ventricular fail- 4. 1. Sponging dry the client’s forehead would be
ure, which could be life threatening. appropriate, but it is not the first intervention.
3. This is a nursing intervention, not a short- 2. Obtaining a pulse oximeter reading would be
term goal, for this client. appropriate, but it is not the first intervention.
4. A pulse oximeter reading would be a goal for 3. Taking the vital signs would be appropriate,
impaired gas exchange, not for cardiac output. but it is not the first intervention.
TEST-TAKING HINT: When reading a nursing 4. The nurse must first put the client in a sit-
diagnosis or problem, the test taker must be ting position to decrease the workload of
sure that the answer selected addresses the the heart by decreasing venous return and
problem. An answer option may be appropri- maximizing lung expansion. Then, the nurse
ate care for the disease process but may not could take vital signs and check the pulse ox-
fit with the problem or etiology. Remember, imeter and then sponge the client’s forehead.
when given an etiology in a nursing diagnosis, TEST-TAKING HINT: In a question that asks
the answer will be doing something about the the nurse to set priorities, all the answer op-
problem (etiology). In this question the test tions can be appropriate actions by the nurse
82

for a given situation. The test taker should 7. 1. If a cough develops, the client should notify
apply some guidelines or principles, such as the health-care provider because this is an ad-
Maslow’s hierarchy, to determine what will verse reaction and the HCP will discontinue
give the client the most immediate assistance. the medication.
Content – Medical: Integrated Nursing Process – 2. Orthostatic hypotension may occur with
Implementation: Client Needs – Safe Effective Care ACE inhibitors as a result of vasodilation.
Environment, Management of Care: Cognitive Level – Therefore, the nurse should instruct the
Synthesis: Concept – Perfusion. client to rise slowly and sit on the side of
the bed until equilibrium is restored.
5. 1. Pitting edema changing from 3+ to 4+
3. ACE inhibitors may cause the client to retain
indicates a worsening of the CHF.
potassium; therefore, the client should not in-
2. The client’s ability to take the radial pulse
crease potassium intake.
would evaluate teaching, not medical
4. An ACE inhibitor should be taken one (1) hour
treatment.
before meals or two (2) hours after a meal to
3. Being able to perform activities of daily living
increase absorption of the medication.
(ADLs) without shortness of breath (dys-
pnea) would indicate the client’s condition is TEST-TAKING HINT: If the test taker knows that
improving. The client’s heart is a more effec- an ACE inhibitor is also given for hyperten-
tive pump and can oxygenate the body better sion, then looking at answer options referring
without increasing fluid in the lungs. to hypotension would be appropriate.
4. Any jugular vein distention indicates that the Content – Medical: Integrated Nursing Process – Planning:
right side of the heart is failing, which would Client Needs – Physiological Integrity, Pharmacological and
not indicate effective medical treatment. Parenteral Therapies: Cognitive Level – Synthesis: Concept –
Perfusion.
TEST-TAKING HINT: When asked to determine
whether treatment is effective, the test taker 8. 1. An S3 heart sound indicates left ventricu-
must know the signs and symptoms of the dis- lar failure, and the nurse must assess this
ease being treated. An improvement in the signs client first because it is an emergency
and symptoms indicates effective treatment. situation.
Content – Medical: Integrated Nursing Process – 2. The nurse would expect a client with CHF to
Assessment: Client Needs – Physiological Integrity, have sacral edema of 4+; the client with an S3
Reduction of Risk Potential: Cognitive Level – Analysis: would be in a more life-threatening situation.
Concept – Perfusion. 3. A pulse oximeter reading of greater than 93%
is considered normal.
6. 1. BNP is a specific diagnostic test. Levels
4. An elevated creatinine level is expected in a cli-
higher than normal indicate congestive
ent diagnosed with chronic renal failure.
heart failure, with the higher the number,
the more severe the CHF. TEST-TAKING HINT: Because the nurse will be
2. An elevated CK-MB would indicate a myocar- assessing each client, the test taker must de-
dial infarction, not severe CHF. CK-MB is an termine which client is a priority. A general
isoenzyme. guideline for this type of question is for the
3. A positive D-dimer would indicate a pulmo- test taker to ask “Is this within normal lim-
nary embolus. its?” or “Is this expected for the disease pro-
4. A positive ventilation/perfusion (V/Q) scan cess?” If the answer is yes to either question,
(ratio) would indicate a pulmonary embolus. then the test taker can eliminate these options
and look for abnormal data that would make
TEST-TAKING HINT: This question requires the
that client a priority.
test taker to discriminate among CHF, MI,
and PE. If unsure of the answer of this type of Content – Medical: Integrated Nursing Process –
question, the test taker should eliminate any Assessment: Client Needs – Safe Effective Care Environ-
ment, Management of Care: Cognitive Level – Evaluation:
answer options that the test taker knows are
Concept – Perfusion.
wrong. For example, the test taker may not
know about pulmonary embolus but might 9. 1. Allowing the UAP to take a client down to
know that CK-MB data are used to monitor smoke is not cost effective and is not sup-
MI and be able to eliminate option “2” as a portive of the medical treatment regimen that
possibility. Then, there is a 1:3 chance of get- discourages smoking.
ting the correct answer. 2. The client going to the ICU would be unstable,
Content – Medical: Integrated Nursing Process – and the nurse should not delegate to a UAP any
Assessment: Client Needs – Physiological Integrity, nursing task that involves an unstable client.
Reduction of Risk Potential: Cognitive Level – Analysis: 3. The nurse cannot delegate teaching.

4. The UAP can assist the x-ray technician return to the central circulation, but these in-
in positioning the client for the portable terventions would not help with leg cramps.
x-ray. This does not require judgment. 4. Ambulating frequently and performing leg-
TEST-TAKING HINT: The test taker must be stretching exercises will not be effective in
knowledgeable about the individual state’s alleviating the leg cramps.
Nurse Practice Act regarding what a nurse TEST-TAKING HINT: The timing “at night” in
may delegate to unlicensed assistive person- this question was not important in answering
nel. Generally, the answer options that re- the question, but it could have made the test
quire higher level of knowledge or ability are taker jump at option “1.” Be sure to read all
reserved for licensed staff. answer options before deciding on an answer.
Content – Medical: Integrated Nursing Process – Answering this question correctly requires
Planning: Client Needs – Safe Effective Care Environ- knowledge of the side effects of treatments
ment, Management of Care: Cognitive Level – Synthesis: used for CHF.
Concept – Nursing Roles. Content – Medical: Integrated Nursing Process –
10. 1. This client is stable because discharge is Implementation: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Application:
scheduled for the following day. Therefore,
this client does not need to be assigned to the
most experienced registered nurse. 12. 1. Measuring the intake and output is an
2. This client is more in need of custodial nurs- appropriate intervention to implement for
ing care than care from the most experienced a client with CHF, but it does not address
registered nurse. Therefore, the charge nurse getting the client to tolerate activity.
could assign a less experienced nurse to this 2. Dietary sodium is restricted in clients
client. with CHF, but this is an intervention for
3. This client is exhibiting signs/symptoms decreasing fluid volume, not for increasing
of shock, which makes this client the most tolerance for activity.
unstable. An experienced nurse should 3. Daily weighing monitors fluid volume status,
care for this client. not activity tolerance.
4. These complaints usually indicate muscular 4. Scheduling activities and rest periods
or pleuritic chest pain; cardiac chest pain does allows the client to participate in his or
not fluctuate with inspiration. This client her own care and addresses the desired
does not require the care of an experienced outcome.
nurse as much as does the client with signs of TEST-TAKING HINT: With questions involving
shock. nursing diagnoses or goals and outcomes,
TEST-TAKING HINT: When deciding on an the test taker should realize that all activi-
answer for this type of question, the test ties referred to in the answer options may be
taker should reason as to which client is appropriate for the disease but may not be
stable and which has a potentially higher specific for the desired outcome.
level of need. Content – Medical: Integrated Nursing Process –
Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care
Planning: Client Needs – Safe Effective Care Environ- Environment, Management of Care: Cognitive Level –
ment, Management of Care: Cognitive Level – Synthesis: Application: Concept – Perfusion.

11. 1. The client with peripheral edema will experi- Angina/Myocardial Infarction
ence calf tightness but would not have leg
cramping, which is the result of low potas- 13. 1. CK-MB elevates in 12 to 24 hours.
sium levels. The timing of the diuretic will 2. Lactic dehydrogenase (LDH) elevates in
not change the side effect of leg cramping 24 to 36 hours.
resulting from low potassium levels. 3. Troponin is the enzyme that elevates
2. The most probable cause of the leg within 1 to 2 hours.
cramping is potassium excretion as a re- 4. WBCs elevate as a result of necrotic tissue,
sult of diuretic medication. Bananas and but this is not a cardiac enzyme.
orange juice are foods that are high in
TEST-TAKING HINT: The test taker should
potassium.
be aware of the words “cardiac enzyme,”
3. Weight gain is monitored in clients with
which would eliminate option “4” as a pos-
CHF, and elevating the legs would decrease
sible answer. The word in the stem is “first.”
peripheral edema by increasing the rate of

This questionrequires the test taker to have Content – Medical: Integrated Nursing Process –
knowledge of laboratory values. Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level –
Content – Medical: Integrated Nursing Process –
Synthesis: Concept – Perfusion.
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis: 16. 1. Morphine should be administered intrave-
Concept – Perfusion. nously, not intramuscularly.
14. 1. Midepigastric pain would support a d iagnosis 2. Aspirin is an antiplatelet medication and
of peptic ulcer disease; pyrosis is belching. should be administered orally.
2. Diaphoresis (sweating) is a systemic reac- 3. Oxygen will help decrease myocardial
tion to the MI. The body vasoconstricts ischemia, thereby decreasing pain.
to shunt blood from the periphery to the 4. The supine position will increase respiratory
trunk of the body; this, in turn, leads to effort, which will increase myocardial oxy-
cold, clammy skin. gen consumption; the client should be in the
3. Intermittent claudication is leg pain semi-Fowler’s position.
secondary to decreased oxygen to the muscle, 5. Nitroglycerin, a coronary vasodilator, is ad-
and pallor is paleness of the skin as a result of ministered sublingually, not subcutaneously.
decreased blood supply. Neither is an early TEST-TAKING HINT: This is an alternate-type
sign of MI. question that requires the test taker to select
4. Jugular vein distension (JVD) and dependent all options that are applicable. The test taker
edema are signs/symptoms of congestive must identify all correct answer options to
heart failure, not of MI. receive credit for a correct answer; no partial
TEST-TAKING HINT: The stem already ad- credit is given. Remember to read the ques-
dresses chest pain; therefore, the test taker tion carefully—it is not meant to be tricky.
could eliminate option “1” as a possible an- Content – Medical: Integrated Nursing Process –
swer. Intermittent claudication, option “3,” is Implementation: Client Needs – Safe Effective Care
the classic sign of arterial occlusive disease, Environment, Management of Care: Cognitive Level –
and JVD is very specific to congestive heart Analysis: Concept – Perfusion.
failure. The nurse must be able to identify at 17. 1. The social worker addresses financial con-
least two or three signs/symptoms of disease cerns or referrals after discharge, which are
processes. not indicated for this client.
Content – Medical: Integrated Nursing Process – 2. Physical therapy addresses gait problems,
Assessment: Client Needs – Physiological Integrity, lower extremity strength building, and assist-
Reduction of Risk Potential: Cognitive Level – Analysis: ing with transfer, which are not required for
Concept – Perfusion. this client.
15. 1. The nurse must assume the chest pain 3. Cardiac rehabilitation is the most
is secondary to decreased oxygen to the appropriate referral. The client can start
myocardium and administer a sublingual rehabilitation in the hospital and then
nitroglycerin tablet, which is a coronary attend an outpatient cardiac rehabilitation
vasodilator, but this is not the first action. clinic, which includes progressive exercise,
2. An ECG should be ordered, but it is not the diet teaching, and classes on modifying
first intervention. risk factors.

3. Stopping all activity will decrease the need 4. Occupational therapy assists the client in
of the myocardium for oxygen and may regaining activities of daily living and covers
help decrease the chest pain. mainly fine motor activities.
4. Assessment is often the first nursing interven- TEST-TAKING HINT: The test taker must be
tion, but when the client has chest pain and a familiar with the responsibilities of the other
possible MI, the nurse must first take care of members of the health-care team. If the test
the client. Taking vital signs would not help taker had no idea which would be the most
relieve chest pain. appropriate referral, the word “cardiac,”
TEST-TAKING HINT: Whenever the test taker which means “heart,” should help the test
wants to select an assessment interven- taker in deciding that this is the most sen-
tion, be sure to think about whether that sible option because the client had a myocar-
intervention will help the client, especially dial infarction, a “heart attack.”
if the client is experiencing pain. Do not au- Content – Medical: Integrated Nursing Process –
tomatically select the answer option that is Planning: Client Needs – Safe Effective Care Environ-
assessment. ment, Management of Care: Cognitive Level – Synthesis:
Concept – Collaboration.

18. 1. The nurse should medicate the client as 3. This is not a normal finding; it indicates heart
needed, but it is not the first intervention. failure.
2. The nurse must always assess the client to 4. Morphine is administered for chest pain, not
determine if the chest pain that is occur- for heart failure, which is suggested by the S3
ring is expected postoperatively or if it is a sound.
complication of the surgery. TEST-TAKING HINT: There are some situations
3. Turning will help decrease complications in which the nurse must notify the health-
from immobility, such as pneumonia, but it care provider, and the test taker should not
will not help relieve the client’s pain. automatically eliminate this as a possible
4. The nurse, not a machine, should always take correct answer. The test taker must decide if
care of the client. any of the other three options will help cor-
TEST-TAKING HINT: The stem asks the nurse rect a life-threatening complication. Normal
to identify the first intervention that should assessment concepts should help identify the
be implemented. Therefore, the test taker correct option. The normal heart sounds are
should apply the nursing process and select S1 and S2 (“lubb-dupp”); S3 is abnormal.
an assessment intervention. Both options “2” Content – Medical: Integrated Nursing Process –
and “4” involve assessment, but the nurse— Implementation: Client Needs – Physiological Integrity,
not a machine or diagnostic test—should Reduction of Risk Potential: Cognitive Level – Synthesis:
always assess the client. Concept – Perfusion.
Content – Surgical: Integrated Nursing Process – 21. 1. The apical pulse is within normal limits—
Implementation: Client Needs – Physiological Integrity, 60 to 100 beats per minute.
Reduction of Risk Potential: Cognitive Level – Synthesis:
2. The serum calcium level is not monitored
Concept – Assessment.
when calcium channel blockers are given.
19. 1. After PTCA, the client must keep the right 3. Occasional PVCs would not warrant immedi-
leg straight for at least six (6) to eight (8) ate intervention prior to administering this
hours to prevent any arterial bleeding from medication.
the insertion site in the right femoral artery. 4. The client’s blood pressure is low, and a
2. A pressure dressing is applied to the insertion calcium channel blocker could cause the
site to help prevent arterial bleeding. blood pressure to bottom out.
3. Any neurovascular assessment data that TEST-TAKING HINT: The test taker must know
are abnormal require intervention by the when to question administering medications.
nurse; numbness may indicate decreased The test taker is trying to select an option
blood supply to the right foot. that, if the medication is administered, would
4. A bounding pedal pulse indicates that ad- cause serious harm to the client.
equate circulation is getting to the right foot; Content – Medical: Integrated Nursing Process –
therefore, this would not require immediate Assessment: Client Needs – Physiological Integrity,
intervention. Pharmacological and Parenteral Therapies: Cognitive
TEST-TAKING HINT: This question requires Level – Analysis: Concept – Medication.
the test taker to identify abnormal, unex- 22. 1. Leg movement is an appropriate action,
pected, or life-threatening data. The nurse
and the UAP should not be told to stop

must know that a PTCA is performed by encouraging it.
placing a catheter in the femoral artery and 2. This behavior is not unsafe or dangerous and
that internal or external bleeding is the most should not be reported to the charge nurse.
common complication. 3. The nurse should praise and encourage
Content – Surgical: Integrated Nursing Process – UAPs to participate in the client’s care.
Implementation: Client Needs – Safe Effective Care Clients on bedrest are at risk for deep
vein thrombosis, and moving the legs will
help prevent this from occurring.
20. 1. An S3 indicates left ventricular failure and 4. The nurse should praise subordinates for ap-
should be reported to the health-care propriate behavior, especially when it is help-
provider. It is a potential life-threatening ing to prevent life-threatening complications.
complication of a myocardial infarction.
2. Elevating the head of the bed will not do any-
thing to help a failing heart.

TEST-TAKING HINT: This is a management may occur. Therefore, the test taker must
question. The test taker must know the chain select an answer option that is abnormal or
of command and when to report behavior. unsafe. In the data listed, there are three
The test taker could eliminate options “1” normal findings and one abnormal finding.
and “2” with the knowledge that moving the Content – Medical: Integrated Nursing Process –
legs is a safe activity for the client. When Assessment: Client Needs – Safe Effective Care
having to choose between options “3” and Environment, Management of Care: Cognitive Level –
“4,” the test taker should select doing some- Synthesis: Concept – Perfusion.
thing positive, instead of taking no action.
This is a management concept.
Coronary Artery Disease
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level – 25. 1. If the tablets are not kept in a dark bottle,
Application: Concept – Nursing Roles. they will lose their potency.
2. The tablets should burn or sting when put
23. 1. The heart tissue is dead, stress or activity under the tongue.
may cause heart failure, and it does take 3. The client should keep the tablets with him
about six (6) weeks for scar tissue to form. in case of chest pain.
2. The nurse should talk to the client in lay- 4. The client should take one tablet every
person’s terms, not medical terms. Medical five (5) minutes and, if no relief occurs
terminology is a foreign language to most after the third tablet, have someone
clients. drive him to the emergency department
3. This is not answering the client’s question. or call 911.
The nurse should take any opportunity to
TEST-TAKING HINT: This question is an
teach the client.
“except” question, requiring the test taker to
4. This is a condescending response, and telling
identify which statement indicates the client
the client that he or she is not out of danger
doesn’t understand the teaching. Sometimes
is not an appropriate response.
the test taker could restate the question and
TEST-TAKING HINT: When attempting to think which statement indicates the client
a nswer a client’s question, the nurse should understands the teaching.
provide factual information in simple, under- Content – Medical: Integrated Nursing Process –
standable terms. The test taker should select Evaluation: Client Needs – Physiological Integrity,
the answer option that provides this type of Pharmacological and Parenteral Therapies: Cognitive
information. Level – Application: Concept – Perfusion.
Implementation: Client Needs – Physiological Integrity,
26. 1. This is a correct statement presented
Physiological Adaptation: Cognitive Level – Application: in layman’s terms. When the coronary
Concept – Nursing Roles. arteries cannot supply adequate oxygen to
the heart muscle, there is chest pain.
24. 1. These vital signs are within normal lim- 2. This is the explanation in medical terms that
its and would not require any immediate should not be used when explaining medical
intervention.
conditions to a client.
2. The groin dressing should be dry and intact. 3. This explains congestive heart failure but
3. If the client bends the leg, it could cause does not explain why chest pain occurs.
the insertion site to bleed. This is arterial 4. Respiratory compromise occurs when the
blood and the client could bleed to death lungs cannot oxygenate the blood, such as
very quickly, so this requires immediate occurs with altered level of consciousness,
intervention. cyanosis, and increased respiratory rate.
4. The nurse must check the neurovascular
TEST-TAKING HINT: The nurse must select the
assessment, and paresthesia would warrant
option that best explains the facts in terms
immediate intervention, but no numbness
a client who does not have medical training
and tingling is a good sign.
can understand.
TEST-TAKING HINT: “Warrants immediate in-
tervention” means the nurse should probably Implementation: Client Needs – Physiological Integrity,
notify the health-care provider or do some- Physiological Adaptation: Cognitive Level – Application:
thing independently because a complication Concept – Perfusion.

27. 1. The client’s right leg should be kept straight 29. 1. The nurse should always assess the apical (not
to prevent arterial bleeding from the femoral radial) pulse, but the pulse is not affected by a
insertion site for the catheter used to perform loop diuretic.
the catheterization. 2. Loop diuretics cause potassium to be lost
2. The nurse must make sure that blood is in the urine output. Therefore, the nurse
circulating to the right leg, so the client should assess the client’s potassium level, and
should be assessed for pulses, paresthesia, if the client is hypokalemic, the nurse should
paralysis, coldness, and pallor. question administering this medication.
3. The head of the bed should be elevated no 3. The glucometer provides a glucose level,
more than 10 degrees. The client should which is not affected by a loop diuretic.
be kept on bedrest, flat with the affected 4. The pulse oximeter reading evaluates periph-
extremity straight, to help decrease the eral oxygenation and is not affected by a loop
chance of femoral artery bleeding. diuretic.
4. The gag reflex is assessed if a scope is in- TEST-TAKING HINT: Knowing that diuretics in-
serted down the trachea (bronchoscopy) or crease urine output would lead the test taker
esophagus (endoscopy) because the throat is to eliminate glucose level and oxygenation
numbed when inserting the scope. A catheter (options “3” and “4”). In very few instances
is inserted in the femoral or brachial artery does the nurse assess the radial pulse; the
when performing a cardiac catheterization. apical pulse is assessed.
TEST-TAKING HINT: The nurse should apply Content – Medical: Integrated Nursing Process –
the nursing process when determining the Implementation: Client Needs – Physiological Integrity,
correct answer. Therefore, either option “2” Pharmacological and Parenteral Therapies: Cognitive
or option “4” could possibly be the correct Level – Application: Concept – Medication.
answer. The test taker then should apply
30. 1. A low-fat, low-cholesterol diet will help
anatomy concepts—where is the left femoral
decrease the buildup of atherosclerosis in
artery? Neurovascular assessment is per-
the arteries.
formed on extremities.
2. Walking will help increase collateral
Content – Surgical: Integrated Nursing Process – circulation.
Planning: Client Needs – Physiological Integrity, 3. Salt should be restricted in the diet of a client
with hypertension, not coronary artery disease.
4. Stress reduction is encouraged for clients
28. 1. This blood pressure is normal and the nurse with CAD because this helps prevent
would administer the medication. excess stress on the heart muscle.
2. A beta blocker decreases sympathetic 5. Increasing fiber in the diet will help
stimulation to the heart, thereby decreas- remove cholesterol via the gastrointestinal
ing the heart rate. An apical rate less than system.
60 indicates a lower-than-normal heart TEST-TAKING HINT: This is an alternate-type
rate and should make the nurse question question where the test taker must select all
administering this medication because it interventions that are applicable to the situ-
will further decrease the heart rate. ation. Coronary artery disease is a common
3. A headache will not affect administering the disease, and the nurse must be knowledge-
medication to the client. able about ways to modify risk factors.
4. The potassium level is within normal lim- Content – Medical: Integrated Nursing Process –
its, but it is usually not monitored prior to Planning: Client Needs – Physiological Integrity,
administering a beta blocker. Physiological Adaptation: Cognitive Level – Synthesis:
TEST-TAKING HINT: If the test taker does not Concept – Nursing Roles.
know when to question the use of a certain 31. 1. Bowel movements are important, but they are
medication, the test taker should evaluate not pertinent to coronary artery disease.
the options to determine if any options in- 2. Chest x-rays are usually done for respiratory
clude abnormal data based on normal param- problems, not for coronary artery disease.
eters. This would make the test taker select 3. Sexual activity is a risk factor for angina
option “2” because the normal apical pulse in resulting from coronary artery disease.
an adult is 60 to 100. The client’s being elderly should not af-
Content – Medical: Integrated Nursing Process – fect the nurse’s assessment of the client’s
Assessment: Client Needs – Physiological Integrity, concerns about sexual activity.
Pharmacological and Parenteral Therapies: Cognitive
4. Weight change is not significant in a client
Level – Analysis: Concept – Medication.
with coronary artery disease.

TEST-TAKING HINT: Remember, if the client is 34. 1. The Holter monitor is a 24-hour elec-
described with an adjective such as “elderly,” trocardiogram, and the client must keep
this may be the key to selecting the correct an accurate record of activity so that the
answer. The nurse must not be judgmental health-care provider can compare the ECG
about the elderly, especially about issues recordings with different levels of activity.
concerning sexual activity. 2. The Holter monitor should not be removed
Content – Medical: Integrated Nursing Process – for any reason.
Assessment: Client Needs – Physiological Integrity, 3. All medications should be taken as prescribed.
Reduction of Risk Potential: Cognitive Level – Analysis: 4. The client should perform all activity as usual
Concept – Perfusion. while wearing the Holter monitor so the
HCP can get an accurate account of heart
32. 1. Isometric exercises are weight lifting–type
function during a 24-hour period.
exercises. A client with CAD should perform
isotonic exercises, which increase muscle TEST-TAKING HINT: In some instances, the test
tone, not isometric exercises. taker must be knowledgeable about diagnos-
2. The client should walk at least 30 minutes a tic tests and there are no test-taking hints.
day to increase collateral circulation. The test taker might eliminate option “3” by
3. When it is cold outside, vasoconstriction realizing that, unless the client is NPO for a
occurs, and this will decrease oxygen to the test or surgery, medications are usually taken.
heart muscle. Therefore, the client should Content – Medical: Integrated Nursing Process –
not exercise when it is cold outside. Implementation: Client Needs – Physiological Integrity,
4. The client should wear good, supportive te Reduction of Risk Potential: Cognitive Level – Application:
nnis shoes when ambulating, not sandals or Concept – Perfusion.
other open-toed shoes. 35. 1. According to the American Heart Association,
TEST-TAKING HINT: The test taker should be the client should not eat more than three (3)
aware of adjectives such as “isometric,” which eggs a week, especially the egg yolk.
makes option “1” incorrect, and “open-toed,” 2. The American Heart Association recom-
which makes option “4” incorrect. mends a low-fat, low-cholesterol diet for
Content – Medical: Integrated Nursing Process – a client with coronary artery disease. The
Implementation: Client Needs – Physiological Integrity, client should avoid any fried foods, especially
Physiological Adaptation: Cognitive Level – Application: meats, and bake, broil, or grill any meat.
Concept – Perfusion. 3. The client should drink low-fat milk, not
whole milk.
33. 1. The client should take the coronary vasodila-
4. Pork products (bacon, sausage, ham) are high
tor nitroglycerin sublingually, but it is not the
in sodium, which is prohibited in a low-salt
first intervention.
diet, not a low-cholesterol, low-fat diet.
2. Stopping the activity decreases the heart’s
need for oxygen and may help decrease TEST-TAKING HINT: The test taker must
the angina (chest pain). be knowledgeable of prescribed diets for
3. The client should keep a diary of when an- specific disease processes. This is mainly
gina occurs, what activity causes it, and how memorizing facts. There is no test-taking
many nitroglycerin tablets are taken before hint to help eliminate any of the options.
chest pain is relieved. Content – Medical: Integrated Nursing Process –

4. If the chest pain (angina) is not relieved with Evaluation: Client Needs – Physiological Integrity,
three (3) nitroglycerin tablets, the client Physiological Adaptation: Cognitive Level – Analysis:
should call 911 or have someone take him Concept – Nutrition.
to the emergency department. Notifying the 36. 1. This client is at high risk for complications
HCP may take too long. related to necrotic myocardial tissue and will
TEST-TAKING HINT: The question is asking which need extensive teaching, so this client should
action the client should take first. This implies not be assigned to a new graduate.
that more than one of the answer options could 2. Unstable angina means this client is at risk
be appropriate for the chest pain, but that only for life-threatening complications and should
one is done first. The test taker should select not be assigned to a new graduate.
the answer that will help the client directly and 3. A new graduate should be able to complete
quickly—and that is stopping the activity. a preprocedure checklist and get this client
Content – Medical: Integrated Nursing Process – to the catheterization laboratory.
Planning: Client Needs – Physiological Integrity, Physiologi- 4. Chest pain means this client could be having
cal Adaptation: Cognitive Level – Synthesis: a myocardial infarction and should not be as-
Concept – Perfusion. signed to a new graduate.

TEST-TAKING HINT: “New graduate” is the 39. 1. Prophylactic antibiotics before invasive pro-
key to answering this question correctly. cedures prevent infectious endocarditis.
What type of client should be assigned to an 2. The client is undergoing anticoagulant ther-
inexperienced nurse? The test taker should apy and should use a soft-bristle toothbrush
not assign the new graduate a client who to help prevent gum trauma and bleeding.
is unstable or at risk for a life-threatening 3. Aspirin and nonsteroidal anti-
complication. inflammatory drugs (NSAIDs) interfere
Content – Medical: Integrated Nursing Process – with clotting and may potentiate the ef-
Planning: Client Needs – Safe Effective Care Environ- fects of the anticoagulant therapy, which
ment, Management of Care: Cognitive Level – Synthesis: the client with a mechanical valve will be
Concept – Nursing Roles. prescribed. Therefore, the client should
not take aspirin daily.
Valvular Heart Disease 4. The client should alternate rest with activity
to prevent fatigue to help decrease the work-
37. 1. Dyspnea on exertion (DOE) is typically load of the heart.
the earliest manifestation of mitral valve TEST-TAKING HINT: The stem asks the test
stenosis. taker to identify which behavior means
2. Jugular vein distention (JVD) and 3+ pedal the client does not understand the teach-
edema are signs/symptoms of right-sided ing. Therefore, the test taker should select
heart failure and indicate worsening of the the distracter that does not agree with the
mitral valve stenosis. These signs would not condition. There is no condition for which
be expected in a client with early manifesta- alternating rest with activity would not be
tions of mitral valve stenosis. recommended.
3. Chest pain rarely occurs with mitral valve Content – Medical: Integrated Nursing Process –
stenosis. Evaluation: Client Needs – Physiological Integrity,
4. An enlarged liver and edematous abdomen Physiological Adaptation: Cognitive Level – Synthesis:
are late signs of right-sided heart failure that Concept – Perfusion.
can occur with long-term untreated mitral
40. 1. An advantage of having a biological valve re-
valve stenosis.
placement is that no anticoagulant therapy is
TEST-TAKING HINT: Whenever the test taker needed. Anticoagulant therapy is needed with
reads “rule out,” the test taker should look a mechanical valve replacement.
for data that would not indicate a severe 2. This is an advantage of having a biologi-
condition of the body system that is affected. cal valve replacement; infections are harder
Chest pain, JVD, and pedal edema are late to treat in clients with mechanical valve
signs of heart problems. replacement.
Content – Medical: Integrated Nursing Process – 3. This is an advantage of having a biological
Assessment: Client Needs – Physiological Integrity, valve replacement; there is a high incidence
Reduction of Risk Potential: Cognitive Level – Analysis: of thromboembolism in clients with mechani-
Concept – Perfusion. cal valve replacement.
38. 1. This would be expected with mitral valve 4. Biological valves deteriorate and need to
stenosis. be replaced frequently; this is a disadvan-

2. The murmur associated with mitral tage of them. Mechanical valves do not
valve insufficiency is loud, high pitched, deteriorate and do not have to be replaced
rumbling, and holosystolic (occurring often.
throughout systole) and is heard best at TEST-TAKING HINT: This is an “except”
the cardiac apex. question. The test taker might reverse the
3. This would be expected with mitral valve question and ask, “Which is an advantage
prolapse. of a biological valve?”—which might make
4. This would be expected with aortic answering the question easier.
regurgitation. Content – Medical: Integrated Nursing Process –
TEST-TAKING HINT: This is a knowledge-based Diagnosis: Client Needs – Physiological Integrity,
question and there is no test-taking hint to Physiological Adaptation: Cognitive Level – Knowledge:
help the test taker rule out distracters. Concept – Perfusion.
Reduction of Risk Potential: Cognitive Level – Analysis:

41. 1. The therapeutic range for most clients’ 43. 1. An acute myocardial infarction can damage
INR is 2 to 3, but for a client with a heart valves, causing tearing, ischemia, or
mechanical valve replacement it is 2 to damage to heart muscles that affects valve
3.5. The medication should be given as leaflet function, but coronary heart disease
ordered and not withheld. does not cause valvular heart disease.
2. Vitamin K is the antidote for an overdose of 2. Valvular heart disease does not show a genetic
warfarin, but 2.7 is within the therapeutic etiology.
range. 3. Smoking can cause coronary artery disease,
3. This laboratory result is within the but it does not cause valvular heart disease.
therapeutic range, INR 2 to 3, and the 4. Rheumatic heart disease is the most com-
medication does not need to be withheld. mon cause of valvular heart disease.
4. There is no need for the nurse to assess for TEST-TAKING HINT: The test taker could rule
bleeding because 2.7 is within the therapeutic out option “1” because of knowledge of anat-
range. omy: Coronary artery disease has to do with
TEST-TAKING HINT: The test taker has to blood supply to heart muscle, whereas the
know the therapeutic range for the INR to valves are a part of the anatomy of the heart.
be able to answer this question correctly. The Content – Medical: Integrated Nursing Process –
test taker should keep a list of normal and Assessment: Client Needs – Physiological Integrity,
therapeutic laboratory values that must be Reduction of Risk Potential: Cognitive Level – Analysis:
remembered. Concept – Perfusion.
Content – Medical: Integrated Nursing Process – 44. 1. Percutaneous balloon valvuloplasty is not an
Implementation: Client Needs – Physiological Integrity, open-heart surgery; therefore, the chest will
Pharmacological and Parenteral Therapies: Cognitive
not be open and the client will not have a
Level – Analysis: Concept – Medication.
chest tube.
42. 1. Paroxysmal nocturnal dyspnea is a sudden 2. This is not an open-heart surgery; therefore,
attack of respiratory distress, usually oc- the client will not have a chest dressing.
curring at night because of the reclining 3. The endotracheal (ET) tube is inserted if the
position, and occurs in valvular disorders. client is on a ventilator, and this surgery does
2. This is an abnormal condition in which a not require putting the client on a ventilator.
client must sit or stand to breathe com- 4. In this invasive procedure, performed in a
fortably and occurs in valvular disorders. cardiac catheterization laboratory, the cli-
3. Coughing occurs when the client with ent has a catheter inserted into the femo-
long-term valvular disease has difficulty ral artery. Therefore, the client must keep
breathing when walking or performing the leg straight to prevent hemorrhaging
any type of activity. at the insertion site.
4. Pericardial friction rub is a sound auscultated TEST-TAKING HINT: If the test taker knows
in clients with pericarditis, not valvular heart that the word “percutaneous” means “via
disease. the skin,” then options “1” and “2” could be
5. Pulsus paradoxus is a marked decrease in eliminated as possible correct answers.
amplitude during inspiration. It is a sign of Content – Surgical: Integrated Nursing Process –
cardiac tamponade, not valvular heart disease. Implementation: Client Needs – Physiological Integrity,
TEST-TAKING HINT: The test taker should Reduction of Risk Potential: Cognitive Level – Application:
notice that options “1,” “2,” and “3” are all Concept – Perfusion.
signs/symptoms that have something to do 45. 1. The client is at risk for developing endo-
with the lungs. It would be a good choice to carditis and should take prophylactic anti-
select these three as correct answers. They biotics before any invasive procedure.
are similar in description. 2. Antibiotics have nothing to do with how
Content – Medical: Integrated Nursing Process – much the teeth bleed during a cleaning.
Assessment: Client Needs – Physiological Integrity, 3. Teeth cleaning will not cause the valve to
malfunction.
4. Vegetation develops on valves secondary to
bacteria that cause endocarditis, but the client
may not understand “vegetative growth on
your valves”; therefore, this is not the most
appropriate answer.

TEST-TAKING HINT: The test taker should that possible complications of these problems
s elect an option that answers the client’s do not include mitral valve prolapse.
question in the easiest and most understand- Content – Medical: Integrated Nursing Process –
able terms, not in medical jargon. This would Assessment: Client Needs – Physiological Integrity,
cause the test taker to eliminate option “4” Physiological Adaptation: Cognitive Level – Analysis:
as a possible correct answer. The test taker Concept – Perfusion.
should know antibiotics do not affect bleed- 48. 1. This client requires teaching and an under-
ing and so can eliminate option “2.” standing of the preprocedure interventions for
Content – Surgical: Integrated Nursing Process – diagnostic tests; therefore, a more experienced
Implementation: Client Needs – Physiological Integrity, nurse should be assigned to this client.
Physiological Adaptation: Cognitive Level – Application:
2. Because this client is being discharged, it
would be an appropriate assignment for
46. 1. Fluid intake may be restricted to reduce the new graduate.
the cardiac workload and pressures within 3. Supraventricular tachycardia (SVT) is not
the heart and pulmonary circuit. life threatening, but the client requires in-
2. The head of the bed should be elevated to travenous medication and close monitoring
help improve alveolar ventilation. and therefore should be assigned to a more
3. Oxygen saturation should be no less than experienced nurse.
93%; 90% indicates an arterial oxygen satura- 4. A client with atrial fibrillation is usually tak-
tion of around 60 (normal is 80 to 100). ing the anticoagulant warfarin (Coumadin),
4. Total parenteral nutrition would not be and the therapeutic INR is 2 to 3. An INR of
prescribed for a client with mitral valve 5 is high and the client is at risk for bleeding.
replacement. It is ordered for clients with TEST-TAKING HINT: The test taker must real-
malnutrition, gastrointestinal disorders, or ize that a new graduate must be assigned the
conditions in which increased calories are least critical client. Remember, teaching is a
needed, such as burns. primary responsibility of the nurse; physical
TEST-TAKING HINT: A client with a heart or lung care is not always the criterion that should be
problem should never have the head of the bed used when making client assignments.
in a flat (supine) position; therefore, option “2” Content – Medical: Integrated Nursing Process –
should be eliminated as a possible correct an- Planning: Client Needs – Safe Effective Care Environ-
swer. The test taker must know normal values ment, Management of Care: Cognitive Level – Synthesis:
for monitoring techniques such as pulse oxim- Concept – Nursing Roles.
eters and keep a list of normal values.
Content – Surgical: Integrated Nursing Process –
Dysrhythmias and Conduction Problems
Application: Concept – Perfusion. 49. 1. The telemetry nurse should not leave the
monitors unattended at any time.
47. 1. Congestive heart failure does not predispose 2. The telemetry nurse must have someone
the female client to having a mitral valve go assess the client, but this is not the first
prolapse.
intervention.
2. Clients with Marfan’s syndrome have life- 3. If the client answers the call light and is
threatening cardiovascular problems, in- not experiencing chest pain, then there is
cluding mitral valve prolapse, progressive probably a monitor artifact, which is not a
dilation of the aortic valve ring, and weak- life-threatening emergency. After talking
ness of the arterial walls, and they usually with the client, send a nurse to the room
do not live past the age of 40 because of to check the monitor.
dissection and rupture of the aorta. 4. The crash cart should be taken to a room
3. Atrial fibrillation does not predispose a client when the client is experiencing a code.
to mitral valve prolapse.
TEST-TAKING HINT: When the test taker sees
4. A client with Down syndrome may have con-
the word “first,” the test taker must realize that
genital heart anomalies but not mitral valve
more than one answer option may be a pos-
prolapse.
sible intervention but that only one should be
TEST-TAKING HINT: The test taker could elim- implemented first. The test taker should try to
inate options “1” and “3” based on knowledge determine which intervention directly affects
that these are commonly occurring cardiovas- the client.
cular problems, and the nurse should know

Content – Medical: Integrated Nursing Process – TEST-TAKING HINT: The key to answering
Implementation: Client Needs – Safe Effective Care this question is the adjective “collaborative,”
Environment, Management of Care: Cognitive Level – which means the treatment requires obtain-
Synthesis: Concept – Perfusion. ing a health-care provider’s order or work-
50. 1. There are many interventions that should ing with another member of the health-care
be implemented prior to administering team. This would cause the test taker to elim-
medication. inate option “2” as a possible correct answer.
2. The treatment of choice for ventricular fibril- Content – Medical: Integrated Nursing Process –
lation is defibrillation, but it is not the first Planning: Client Needs – Physiological Integrity,
action. Reduction of Risk Potential: Cognitive Level – Synthesis:
3. The nurse must call a code that activates Concept – Perfusion.
the crash cart being brought to the room 53. 1. The adult client should be defibrillated at
and a team of health-care providers that 360 joules.
will care for the client according to an es- 2. The oxygen source should be removed
tablished protocol. to prevent any type of spark during
4. The first person at the bedside should start defibrillation.
cardiopulmonary resuscitation (CPR), but the 3. The nurse should use defibrillator pads or
telemetry nurse should call a code so that all defibrillator gel to prevent any type of skin
necessary equipment and personnel are at the burns while defibrillating the client.
bedside. 4. If any member of the health-care team
TEST-TAKING HINT: The test taker must realize is touching the client or the bed during
that ventricular fibrillation is life threatening defibrillation, that person could possibly
and immediate action must be implemented. be shocked. Therefore, the nurse should
Remember, when the question asks “first,” all shout “all clear.”
options could be appropriate interventions TEST-TAKING HINT: The test taker should al-
but only one should be implemented first. ways consider the safety of the client and the
Content – Medical: Integrated Nursing Process – health-care team. Options “2” and “3” put the
Implementation: Client Needs – Safe Effective Care Envi- client at risk for injury during defibrillation.
ronment, Management of Care: Cognitive Level –
51. 1. Amiodarone suppresses ventricular ectopy Environment, Management of Care: Cognitive Level –
and is the drug of choice for ventricular Application: Concept – Perfusion.
dysrhythmias. 54. 1. A client with chronic atrial fibrillation will
2. Atropine decreases vagal stimulation and is be taking an anticoagulant to help prevent
the drug of choice for asystole. clot formation. Therefore, the client is at
3. Digoxin slows heart rate and increases cardiac risk for bleeding and should be instructed
contractility and is the drug of choice for to use a soft-bristle toothbrush.
atrial fibrillation. 2. The client will need a regularly scheduled
4. Adenosine is the drug of choice for supraven- INR to determine the therapeutic level for
tricular tachycardia. the anticoagulant warfarin (Coumadin); PTT
TEST-TAKING HINT: This is a knowledge-based levels are monitored for heparin.

question, and the test taker must know the 3. A client with symptomatic sinus bradycardia,
answer. The nurse must know what medica- not a client with atrial fibrillation, may need a
tions treat specific dysrhythmias. pacemaker.
Content – Medical: Integrated Nursing Process – 4. Synchronized cardioversion may be pre-
Planning: Client Needs – Physiological Integrity, scribed for new-onset atrial fibrillation but
Pharmacological and Parenteral Therapies: Cognitive not for chronic atrial fibrillation.
Level – Synthesis: Concept – Medication. TEST TAKING HINT: In order to choose the
52. 1. A thrombolytic medication is administered for correct answer for this question the test
a client experiencing a myocardial infarction. taker must recognize the disease process,
2. Assessment is an independent nursing a ction, then know what complications are possible,
not a collaborative treatment. and finally the test-taker must know how
3. The client is symptomatic and will require the client can possibly be treated so that the
a pacemaker. complication does not occur.
4. Synchronized cardioversion is used for Content – Medical: Integrated Nursing Process – Planning:
ventricular tachycardia with a pulse or atrial Client Needs – Physiological Integrity, Physiological Adapta-
fibrillation. tion: Cognitive Level – Synthesis: Concept – Nursing Roles.

55. 1. Amiodarone is the drug of choice for ven- 3. Defibrillation is the treatment of choice
tricular tachycardia, but it is not the first for ventricular fibrillation.
intervention. 4. The crash cart has the defibrillator and is
2. Defibrillation may be needed, but it is not the used when performing advanced cardio-
first intervention. pulmonary resuscitation.
3. The nurse must assess the apical pulse and 5. Amiodarone is an antidysrhythmic that is
blood pressure to determine if the client is used in ventricular dysrhythmias.
in cardiac arrest and then treat as ventricu- TEST-TAKING HINT: This is an alternate-type
lar fibrillation. If the client’s heart is beating, question that requires the test taker to pos-
the nurse would then administer lidocaine. sibly select more than one option. To receive
4. CPR is only performed on a client who is credit, the test taker must select all correct
not breathing and does not have a pulse. The options; partial credit is not given for this
nurse must establish if this is occurring first type of question.
prior to taking any other action. Content – Medical: Integrated Nursing Process –
TEST-TAKING HINT: When the stem asks the Implementation: Client Needs – Safe Effective Care
test taker to select the first intervention, all Environment, Management of Care: Cognitive Level –
answer options could be plausible interven- Analysis: Concept – Perfusion.
tions, but only one is implemented first. The 58. 1. The telemetry reading is accurate, and there
test taker should use the nursing process to is no need for the nurse to assess the client’s
answer the question and select the interven- heart rate.
tion that addresses assessment, which is the
2. There is no reason to notify the surgeon for a
first step in the nursing process.
client exhibiting sinus tachycardia.
Content – Medical: Integrated Nursing Process – 3. Synchronized cardioversion is prescribed for
Implementation: Client Needs – Safe Effective Care clients in acute atrial fibrillation or ventricu-
lar fibrillation with a pulse.
4. Sinus tachycardia means the sinoatrial
56. 1. A pacemaker will have to be inserted, but it is node is the pacemaker, but the rate is
not the first intervention. greater than 100 because of pain, anxiety,
2. Atropine will decrease vagal stimulation or fever. The nurse must determine the
and increase the heart rate. Therefore, it cause and treat appropriately. There is no
is the first intervention. specific medication for sinus tachycardia.
3. A STAT ECG may be done, but the telem- TEST-TAKING HINT: The test taker must use
etry reading shows complete heart block, the nursing process to determine the correct
which is a life-threatening dysrhythmia and option and select an option that addresses as-
must be treated. sessment, the first step of the nursing process.
4. The HCP will need to be notified but not Because both option “1” and option “4” address
prior to administering a medication. The test assessment, the test taker must determine
taker must assume the nurse has the order which option is more appropriate. How will
to administer medication. Many telemetry taking the apical pulse help treat sinus tachy-
departments have standing protocols. cardia? Determining the cause for sinus tachy-
TEST-TAKING HINT: The test taker must select cardia is the most appropriate intervention.
the intervention that should be implemented Content – Surgical: Integrated Nursing Process –
first and will directly affect the dysrhythmia. Implementation: Client Needs – Safe Effective Care
Medication is the first intervention, and Environment, Management of Care: Cognitive Level –
then pacemaker insertion. The test taker Application: Concept – Perfusion.
should not eliminate an option because the 59. 1. The P wave represents atrial contraction,
test taker thinks there is not an order by a and the QRS complex represents ven-
health-care provider. tricular contraction—a normal telemetry
Content – Medical: Integrated Nursing Process – reading. A rate between 60 and 100 in-
Implementation: Client Needs – Safe Effective Care dicates normal sinus rhythm. Therefore,
the nurse should document this as normal
sinus rhythm and not take any action.
57. 1. Ventricular fibrillation indicates the client 2. A 12-lead ECG should be requested for chest
does not have a heartbeat. Therefore, pain or abnormal dysrhythmias.
CPR should be instituted. 3. Digoxin is used to treat atrial fibrillation.
2. Adenosine, an antidysrhythmic, is the drug of 4. Cardiac enzymes are monitored to determine
choice for supraventricular tachycardia, not if the client has had a myocardial infarction.
for ventricular fibrillation.

Nothing in the stem indicates the client has s ystem, specifically the outside of the heart.
had an MI. The test taker should select the option that
TEST-TAKING HINT: The test taker must know has something to do with the heart, which is
normal sinus rhythm, and there are no test- either option “1” or option “4.”
taking hints to help eliminate incorrect op- Content – Medical: Integrated Nursing Process –
tions. The test taker should not automatically Assessment: Client Needs – Physiological Integrity,
select assessment as the correct answer, but Reduction of Risk Potential: Cognitive Level – Analysis:
if the test taker had no idea of the answer, re- Concept – Perfusion.
member assessment of laboratory data is not 62. 1. Acute pericardial effusion interferes
the same as assessing the client. with normal cardiac filling and pumping,
Content – Medical: Integrated Nursing Process – causing venous congestion and decreased
Implementation: Client Needs – Safe Effective Care cardiac output. Muffled heart sounds,
Environment, Management of Care: Cognitive Level – indicative of acute pericarditis, must be
Application: Concept – Perfusion. reported to the health-care provider.
60. 1. Not every cardiac dysrhythmia causes 2. Distended, not nondistended, jugular veins
alteration in comfort; angina is caused by would warrant immediate intervention.
decreased oxygen to the myocardium. 3. Decreasing quality of peripheral pulses, not
2. Any abnormal electrical activity of the bounding peripheral pulses, would warrant
heart causes decreased cardiac output. immediate intervention.
3. Impaired gas exchange is the result of pulmo- 4. A pericardial friction rub is a classic symptom
nary complications, not cardiac dysrhythmias. of acute pericarditis, but it would not warrant
4. Not all clients with cardiac dysrhythmias have immediate intervention.
activity intolerance. TEST-TAKING HINT: This is a priority setting
TEST-TAKING HINT: Option “2” has the word question, the test taker should determine if
“cardiac,” which refers to the heart. Therefore, the data provided is abnormal or expected for
even if the test taker had no idea what the cor- the the disease process. If so, then the test
rect answer was, this would be an appropriate taker can consider the option as being the
option. The test taker should use medical ter- correct answer. If the data is within normal
minology to help identify the correct option. limits aor expected for the disease process
then the option is not a priority.
Diagnosis: Client Needs – Physiological Integrity, Content – Medical: Integrated Nursing Process –
Physiological Adaptation: Cognitive Level – Analysis: Assessment: Client Needs – Safe Effective Care
Concept – Perfusion. Environment, Management of Care: Cognitive Level –
63. 1. A sore throat in the last month would not

Inflammatory Cardiac Disorders support the diagnosis of carditis.
2. Rheumatic fever, a systemic inflammatory
61. 1. Pulsus paradoxus is the hallmark of cardiac
disease caused by an abnormal immune re-
tamponade; a paradoxical pulse is markedly
sponse to pharyngeal infection by group A
decreased in amplitude during inspiration.
beta-hemolytic streptococci, causes cardi-
2. Fatigue and arthralgias are nonspecific

tis in about 50% of people who develop it.
signs/symptoms that usually occur with
3. Carditis is not a genetic or congenital disease
myocarditis.
process.
3. Petechiae on the trunk, conjunctiva, and
4. This is an appropriate question to ask any
mucous membranes and hemorrhagic streaks
client, but OTC medications do not cause
under the fingernails or toenails occur with
carditis.
endocarditis.
4. Chest pain is the most common symp- TEST-TAKING HINT: This is a knowledge-based
tom of pericarditis, usually has an abrupt question, but the test taker could eliminate
onset, and is aggravated by respiratory option “4,” realizing this is a question to ask
movements (deep inspiration, coughing), any client, and the stem asks which question
changes in body position, and swallowing. will support the diagnosis of carditis.
TEST-TAKING HINT: The test taker who has no Content – Medical: Integrated Nursing Process –
idea what the answer is should apply the test-
taking strategy of asking which body sys- Concept – Perfusion.
tem is affected. In this case, it is the cardiac

64. 1. Steroids, such as prednisone, not NSAIDs, TEST-TAKING HINT: “Collaborative” means
must be tapered off to prevent adrenal another member of the health-care team
insufficiency. must order or participate in the intervention.
2. NSAIDs will not make clients drowsy. Therefore, option “4” could be eliminated as
3. NSAIDs must be taken with food, milk, or a possible correct answer.
antacids to help decrease gastric distress. Content – Medical: Integrated Nursing Process –
NSAIDs reduce fever, inflammation, and Planning: Client Needs – Physiological Integrity,
pericardial pain. Reduction of Risk Potential: Cognitive Level – Synthesis:
4. NSAIDs should be taken regularly around Concept – Perfusion.
the clock to help decrease inflammation, 67. 1. The full course of antibiotics must be taken
which, in turn, will decrease pain. to help ensure complete destruction of strep-
TEST-TAKING HINT: The test taker must re- tococcal infection.
member NSAIDs and steroids cause gastric 2. Antibiotics kill bacteria but also destroy
distress to the point of causing peptic ulcer normal body flora in the vagina, bowel, and
disease. These medications are administered mouth, leading to a superinfection.
for a variety of conditions and diseases. 3. Even with antibiotic treatment for
Content – Medical: Integrated Nursing Process – rheumatic fever, the client may experience
Planning: Client Needs – Physiological Integrity, bacterial endocarditis in later years and
Pharmacological and Parenteral Therapies: Cognitive should know this may occur.
Level – Synthesis: Concept – Medication. 4. A throat culture is taken to diagnose group A
65. 1. Oxygen may be needed, but it is not the first beta-hemolytic streptococcus and is positive
intervention. in 25% to 40% of clients with acute rheu-
2. This would be appropriate to determine if the matic fever.
urine output is at least 30 mL/hr, but it is not TEST-TAKING HINT: The question is asking
the first intervention. the test taker to identify which statement
3. The nurse must assess the client to deter- indicates the client does not understand the
mine if the pain is expected secondary to teaching; this is an “except” question. The
pericarditis or if the pain is indicative of test taker can ask which statement indicates
a complication that requires intervention the teaching is effective and choose the one
from the health-care provider. option that is not appropriate.
4. Using the incentive spirometer will increase Content – Medical: Integrated Nursing Process –
the client’s alveolar ventilation and help Evaluation: Client Needs – Physiological Integrity,
prevent atelectasis, but it is not the first Pharmacological and Parenteral Therapies: Cognitive
intervention. Level – Synthesis: Concept – Medication.
TEST-TAKING HINT: The test taker must ap- 68. 1. Pulmonary embolus would occur with an
ply the nursing process when determining embolization of vegetative lesions from the
the correct answer and select the option tricuspid valve on the right side of the heart.
that addresses the first step in the nursing 2. Bacteria enter the bloodstream from inva-
process—assessment. sive procedures, and sterile platelet-fibrin
Content – Medical: Integrated Nursing Process – vegetation forms on heart valves. The
Implementation: Client Needs – Safe Effective Care mitral valve is on the left side of the heart
Environment, Management of Care: Cognitive Level – and, if the vegetation breaks off, it will
Synthesis: Concept – Perfusion. go through the left ventricle into the sys-
66. 1. A pericardiocentesis removes fluid from temic circulation and may lodge in the
the pericardial sac and is the emergency brain, kidneys, or peripheral tissues.
treatment for cardiac tamponade. 3. Coughing up blood (hemoptysis) occurs
2. Cardiac enzymes may be slightly elevated be- when the vegetation breaks off the tricuspid
cause of the inflammatory process, but evalu- valve in the right side of the heart and enters
ation of these would not be ordered to treat the pulmonary artery.
or evaluate cardiac tamponade. 4. Deep vein thrombosis is a complication of
3. A 12-lead ECG would not help treat the immobility, not of a vegetative embolus from
medical emergency of cardiac tamponade. the left side of the heart.
4. Assessment by the nurse is not collaborative; TEST-TAKING HINT: If the test taker does not
it is an independent nursing action. know the answer, knowledge of anatomy may
help determine the answer. The mitral valve
is on the left side of the heart and any emboli

would not enter the lung first, thereby Content – Medical: Integrated Nursing Process –
eliminating options “1” and “3” as possible Planning: Client Needs – Physiological Integrity,
correct answers. Physiological Adaptation: Cognitive Level – Synthesis:
Concept – Nursing Roles.
Assessment: Client Needs – Physiological Integrity, 71. 1. The nurse should monitor the vital signs
Reduction of Risk Potential: Cognitive Level – Analysis: for any client who has just undergone
Concept – Perfusion. surgery.
69. 1. Anxiety is a psychosocial nursing diagnosis, 2. A pericardiocentesis involves entering
which is not a priority over a physiological the pericardial sac. Assessing heart and
nursing diagnosis. lung sounds allows assessment for cardiac
2. Antibiotic therapy does not result in injury to failure.
the client. 3. The pericardial fluid is documented as
3. Myocarditis does not result in valve damage output.
(endocarditis does), and there would be de- 4. Evaluating the client’s cardiac rhythm
creased, not increased, cardiac output. allows the nurse to assess for car-
4. Activity intolerance is priority for the diac failure, which is a complication of
client with myocarditis, an inflammation pericardiocentesis.
of the heart muscle. Nursing care is aimed 5. The client should be in the semi-Fowler’s po-
at decreasing myocardial work and main- sition, not in a flat position, which increases
taining cardiac output. the workload of the heart.
TEST-TAKING HINT: If the test taker has no TEST-TAKING HINT: This is an alternate-type
idea which is the correct answer, then “myo,” question that requires the test taker to select
which refers to muscle, and “card,” which re- possibly more than one option as a correct
fers to the heart, should lead the test taker to answer.
the only option which has both muscle and Content – Medical: Integrated Nursing Process –
heart in it, o
ption “4.” Implementation: Client Needs – Safe Effective Care
Application: Concept – Perfusion.
Diagnosis: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Analysis: 72. 1. The nurse must obtain blood cultures prior
Concept – Perfusion. to administering antibiotics.
70. 1. Uninterrupted rest and sleep help de- 2. Blood cultures must be done before ad-
crease the workload of the heart and help ministering antibiotics so that an a dequate
ensure the restoration of physical and number of organisms can be obtained to
emotional health. culture and identify.
2. Occupational therapy addresses activities of 3. An echocardiogram allows visualization of
daily living. The client should be referred to vegetations and evaluation of valve function.
physical therapy to develop a realistic and However, antibiotic therapy is a priority be-
progressive plan of activity. fore diagnostic tests, and blood cultures must
3. The client with pericarditis is not usually be obtained before administering medication.
prescribed oxygen, and 2 L/min is a low 4. Bedrest should be implemented, but the first
dose of oxygen that is prescribed for a client intervention should be obtaining blood cul-
with chronic obstructive pulmonary disease tures so that antibiotic therapy can be started
(COPD). as soon as possible.
4. Endocarditis, not pericarditis, may lead to TEST-TAKING HINT: The test taker must iden-
surgery for valve replacement. tify the first of the HCP’s orders to be imple-
TEST-TAKING HINT: A concept that the test mented. “Infective” should indicate that this
taker must remember with any client being is an infection, which requires antibiotics,
discharged from the hospital should be to but the nurse should always assess for aller-
alternate rest with activity to avoid problems gies and obtain cultures prior to administer-
associated with immobility. If the test taker ing any antibiotic.
does not know the answer to a question, us- Content – Medical: Integrated Nursing Process –
ing basic concepts is the best option. Implementation: Client Needs – Safe Effective Care
Application: Concept – Perfusion.

CONCEPTS
73. 1. The HCP will be notified but the first action 75. 1. The client should be monitored for any
is to call for the Code Blue team and initiate cardiovascular changes.
CPR. 2. The client should be monitored for the
2. A Rapid Response Team is called to prevent development of heart failure as a result
an arrest situation from occurring. This client of increased strain on the heart from the
is in an arrest situation. atria not functioning as they should.
3. The client has clinical signs of death; CPR 3. There is no evidence that the client requires
must be initiated and the code team notified. to sleep in the orthopneic position.
4. The first action is to immediately no- 4. Buerger Allen exercises are useful for clients
tify the code team and initiate CPR per who have peripheral artery disease but do not
protocol. have an effect on atrial fibrillation.
TEST-TAKING HINT: The test taker should 5. Clients who have been diagnosed with
remember “If in stress do not assess.” The atrial fibrillation are at risk for develop-
nurse has enough information given in the ing emboli from the stasis of blood in the
stem of the question to initiate an action. The atria. If an emboli breaks loose from the
question asks for a first; all of the options lining of the atria then it can travel to the
may be implemented but only one is first. lungs (right) or to the brain (left).
6. Clients who have been diagnosed with
Implementation: Client Needs – Physiological Integrity, atrial fibrillation are at risk for develop-
Physiological Adaptation: Cognitive Level – Synthesis: ing emboli from the stasis of blood in the
Concept – Perfusion. atria. If an emboli breaks loose from the
lining of the atria then it can travel to the
74. 1. Although this might be the cause of noncom- lungs (right) or to the brain (left).
pliance, actual side effects of antihypertensive
TEST-TAKING HINT: To answer “Select all that
medications may be more likely. Evidence indi-
apply” questions the test taker should look
cates that the side effect of erectile dysfunction
at each option independently of the others.
is a major reason of noncompliance for males.
Each option becomes a true/false question.
2. This is a mild way of introducing the sub-
ject of side effects to a client not wishing Content – Medical: Integrated Nursing Process –
to admit the medication causes unwanted Implementation: Client Needs – Pharmacologic Integrity:
Cognitive Level – Analysis: Concept – Perfusion/Medication.
effects. It opens the door to more probing
assessment questions. The nurse should 76. 1. This indicates ascites, which can happen in
bring up the subject in order to allow the heart failure but does not necessarily do so;
client to be forthcoming with the issues of it can also be liver failure or another issue.
why he is not taking his medication. 2. Dyspnea occurring at night when the
3. This would be the second question to ask if the client is in a recumbent position indicates
client denies any problems with side effects. that the cardiac muscle is not able to
4. Although in this case the nurse can ask “why” compensate for extra fluid returning to
because it is an interview question and not the heart during sleep.
therapeutic conversation being requested in 3. This could indicate diabetes but not heart
the stem, a more direct question will open the failure.
conversation up better. 4. The client is at risk for heart failure as a result
TEST-TAKING HINT: To answer this question of the MI, but it does not happen with all MI
the test taker must remember that all medi- clients and does not support the diagnosis.
cations have potential side effects. Antihy- TEST-TAKING HINT: The test taker should
pertensive medications can cause erectile read the stem of the question carefully. It is
dysfunction in males, frequently resulting asking for assessment data to support the
in noncompliance with the medication regi- client is in heart failure. Three of the answer
men. The issue is a psychological as well as a options give assessment data; therefore,
physiological one. option “4” can be eliminated. Only one of the
Content – Medical: Integrated Nursing Process – other three gives an option that only occurs
Assessment: Client Needs – Pharmacologic Integrity: Cog- with heart failure.
nitive Level – Analysis: Concept – Perfusion/Medication.
98

Content – Medical: Integrated Nursing Process – 4. This strip indicates normal sinus rhythm;
Assessment: Client Needs – Physiological Integrity, there is no need for further action based on
Physiological Adaptation: Cognitive Level – Synthesis: the strip.
77. 1. Nitroglycerin tablets are dispensed in recognize normal values and results in order
small brown bottles to preserve the po- to recognize abnormals. A normal result can
tency. The client should not change the rule out an answer in a “which do you assess
tablets to another container. first” question; an abnormal value automati-
2. The tablets are placed under the tongue to cally elevates the need to see that client be-
dissolve and thereby work more rapidly. fore another one.
3. The client is taught to take one (1) tablet ev- Content – Medical: Integrated Nursing Process –
ery 5 minutes and if the angina is not relieved Implementation: Client Needs – Physiological Integrity,
to call 911. Physiological Adaptation: Cognitive Level – Synthesis:
4. The tablets do not have a fruity odor; they Concept – Perfusion.
sting when placed under the tongue if they
80. 1. Amiodarone is administered during a code
are potent.
rapidly after being mixed in 100 mL of
TEST-TAKING HINT: The test taker should be fluid.
knowledgeable of common medications and 2. Amiodarone is not pushed; lidocaine is
what to teach the client. administered by this method. Amiodarone is
Content – Medical: Integrated Nursing Process – replacing the use of lidocaine during a code
Implementation: Client Needs – Physiological Integrity, because of evidence-based practice.
Physiological Adaptation: Cognitive Level – Synthesis: 3. Amiodarone is ACLS recommended.
Concept – Perfusion. 4. Dopamine is administered via mg/kg/min.
78. 1. The client has not arrested. The nurse might The time to calculate this kind of dosage is
call the rapid response team (RRT) but not a not taken until after the code is concluded
code blue. and the client is placed on a vasopressor
2. The client is in distress; the nurse should medication such as dopamine.
implement a procedure that will alleviate the TEST-TAKING HINT: The test taker should be
distress. knowledgeable of common medications and
3. The client is in distress; the nurse should basic rules of administration.
implement a procedure that will alleviate the Content – Medical: Integrated Nursing Process –
distress. Implementation: Client Needs – Pharmacological
4. The client began to have a problem Adaptation: Cognitive Level – Synthesis: Concept –
during physical exertion. Stopping the Perfusion/Medication.
exertion should be the first action taken
81. 1. “Has developed” indicates a new issue;
by the nurse.
the nurse should notify the HCP of the
TEST-TAKING HINT: The test taker should re- assessment findings, which indicate that
member “If in stress do not assess.” The nurse the client has developed heart failure.
has enough information given in the stem of 2. What the client ate has no bearing on the
the question to initiate an action. The ques-
new development of the clinical manifesta-

tion asks for a first. All of the options may be tions of heart failure.
implemented but only one is first. 3. A 12-lead ECG will not treat heart failure.
Content – Medical: Integrated Nursing Process – 4. A diuretic may need to be administered but
Implementation: Client Needs – Physiological Integrity, notifying the HCP is first.
Physiological Adaptation: Cognitive Level – Synthesis:
read every word in the stem of the question;
79. 1. This strip indicates normal sinus rhythm; “has developed” indicates a newly occurring
there is no need for further action based on situation for the client. The nurse must no-
the strip. tify the HCP when new issues occur in order
2. This strip indicates normal sinus rhythm; to intervene before a failure to rescue issue
there is no need for further action based on occurs.
the strip. Content – Medical: Integrated Nursing Process –
3. This strip indicates normal sinus rhythm; Implementation: Client Needs – Physiological Integrity,
there is no need for further action based Physiological Adaptation: Cognitive Level – Synthesis:
on the strip. The nurse should continue to Concept – Perfusion.
monitor the client.

82. 1. The potassium level is within normal range; clothing (gown, underwear, jeans, etc.)
this medication would not be questioned. and report a weight gain of 3 pounds in a
2. Digoxin is given to clients with rapid atrial week to the HCP.
fibrillation to slow the heart rate; this medi- 4. The nurse should not assess for edema in
cation would not be questioned. the feet and lower legs, but if the client
3. Enalapril, an ACE inhibitor, will lower is in bed the lowest part of the body may
the blood pressure even more. The nurse be in the sacral area. Whichever area is
should hold the medication and notify the dependent is where the nurse should look
HCP that the medication is being held. for edema.
4. This would be the first medication to be 5. The client should drink enough fluids to
administered because it indicates a potential maintain body function, but 3,000 mL is
cardiac muscle perfusion issue. excessive.
TEST-TAKING HINT: The test taker should 6. Whenever the nurse is instructing a client,
recognize normal values and results in order the nurse should determine if the client
to recognize abnormals. A normal result can heard and understood the instructions.
rule out an answer in “Which do you assess Having the client repeat the instructions
first?” or “Which would the nurse question?” is one way of determining “hearing.”
An abnormal value indicates a need for some Having the client return demonstrate is a
action on the part of the nurse. method of determining understanding.
Content – Medical: Integrated Nursing Process – TEST-TAKING HINT: The new NCLEX-RN
Assessment: Client Needs – Pharmacological Integrity: Cog- test plan report states that “Select all that ap-
nitive Level – Synthesis: Concept – Perfusion/Medication. ply” questions may have five (5) to six (6) op-
tions, and one option must be correct but all
83. 1. Activity intolerance is a result of lack of per-
may be correct. In order to answer a “Select
fusion of the cardiac muscle, but the priority
all that apply” question each option is con-
is to get the muscle perfused.
sidered separately as a true/false question.
2. Pain does not kill anyone; the reason behind
the pain could. In the case of chest pain the Content – Medical: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
cardiac muscle is not being perfused, which
causes the pain. Concept – Perfusion.
3. The problem is not having enough oxygen
available to the body but that the oxygen is 85. 1. This could be nothing serious (artifact) but
not being perfused to the cardiac muscle. from the appearance of the strip, the nurse
4. The cardiac muscle is not perfused when cannot tell if the client is in an arrest situ-
there is a narrowing of the arteries caused ation; the nurse must personally assess the
by CAD or when an embolus or a throm- situation. The nurse cannot delegate an un-
bus occludes the artery. Adequate perfu- stable client.
sion will supply oxygen to the cardiac 2. The nurse must determine the situation
muscle, allow for increased activity, and personally; this could be artifact or ven-
decrease pain. tricular fibrillation.
TEST-TAKING HINT: The test taker should 3. This could be nothing serious (artifact) but
remember basic pathophysiology to answer from the appearance of the strip, the nurse
this priority question. The other three inter- cannot tell if the client is in an arrest situa-
related concepts are based on the issue of tion; the nurse must personally assess the sit-
tissue perfusion. uation. Telemetry monitoring is accomplished
using lead II; the monitor tech does not have
the ability to change the lead placement.
Physiological Adaptation: Cognitive Level – Synthesis: 4. The nurse must assess the client prior to
Concept – Perfusion. making a decision as to whether to notify the
code team or not.
84. 1. A dietitian can assist the nurse in
TEST-TAKING HINT: The rules for delegation
explaining the sodium restrictions to the
are the nurse cannot delegate an unstable
client as well as hidden sources of sodium.
client, teaching, assessment, evaluation, or
2. This will help the client’s body to return
medication administration to a UAP. This
excess fluid to the heart for removal from
would eliminate option “1.” Calling a code
the body by the kidneys.
without assessing the client would eliminate
3. The client should weigh himself/herself
option “4.”
every morning in the same type of

Content – Medical: Integrated Nursing Process – 2. The nurse should make sure the client is
Implementation: Client Needs – Physiological Integrity, aware of when sexual activity can be safely
Physiological Adaptation: Cognitive Level – Synthesis: resumed.
Concept – Perfusion/Collaboration. 3. The client needs to know how to take nitro-
86. 1. “Down and dirty” rounds include assess- glycerin but not the pharmacology of how the
ing each client for the main focus of the medication works.
client’s admission or any new issue that is 4. The client can sleep in any position of comfort.
reported from the shift report and assess- TEST-TAKING HINT: The test taker should
ing all lines and tubes going into or com- recognize certain words such as “any,” “all,”
ing out of the client. Once this is done the “never,” or “always.” These absolutes will de-
nurse knows then that the client is stable termine if an option is incorrect or correct.
and a full head-to-toe assessment can be Content – Medical: Integrated Nursing Process –
done at a later time. Planning: Client Needs – Physiological Integrity,
2. The UAP will determine when and how Physiological Adaptation: Cognitive Level – Synthesis:
to accomplish the job; the nurse may assist Concept – Perfusion.
the UAP by informing the UAP of situa-
89. 1. Digoxin is a routine medication that will be
tions which may impact the timing of the
administered at 0900 in most hospitals.
baths, but this is not the purpose of morning
2. The client intends on eating breakfast and
rounds.
this is a scheduled medication for before
3. This is the UAP’s job.
meals.
4. This is not the purpose of morning rounds.
3. This client is showing that the diuretic is
TEST-TAKING HINT: Option “3” has the word doing what it should do. This medication will
“all,” which could eliminate it from consider- be given at 0900.
ation because rarely does an “all” apply. 4. This is a slightly abnormal blood pressure but
Options “2” and “3” are doing the UAP’s job is in acceptable range for someone prescribed
and option “4” is the housekeeping’s job. an ARB, angiotensin receptor blocker. The
Content – Medical: Integrated Nursing Process – medication can be administered at 0900.
Assessment: Client Needs – Physiological Integrity, TEST-TAKING HINT: The test taker should be
knowledgeable of common medications and
Concept – Perfusion/Collaboration.
the basic rules of administration.
87. 1. A complaint of indigestion could be car- Content – Medical: Integrated Nursing Process –
diac chest pain. The nurse should assess Implementation: Client Needs – Pharmacological
this client because of the diagnosis of Adaptation: Cognitive Level – Synthesis: Concept –
CAD and the word “severe” in the option. Perfusion/Medication.
2. Edema is expected for the client diag-
90. 1. CAD narrows the arteries of the heart,
nosed with heart failure, and it is not life
causing the tissues not to be perfused,
threatening.
especially when an embolus or a thrombus
3. An irregular heart rate is not life threaten-
occurs.
ing, and 110 is abnormal but also not life
2. DI is a disease of the pituitary gland or the
threatening.
kidneys; it is not a perfusion issue.

4. Constipation is not life threatening albeit
3. COPD is an oxygenation issue, not a perfu-
uncomfortable.
sion one.
TEST-TAKING HINT: A first makes the test 4. Multiple fractures do not cause perfusion
taker determine which client has the greatest issues unless an interrelated issue occurs.
need. Expected and not life-threatening is-
sues do not require being a priority.
remember basic pathophysiology and the
Content – Medical: Integrated Nursing Process – resulting problems associated with different
Assessment: Client Needs – Physiological Integrity, pathology.
Concept – Perfusion. Content – Medical: Client Needs – Physiological Integrity,
88. 1. The word “any” makes this a wrong option. Concept – Perfusion.
The nurse should teach the client what to do
if chest pain occurs. Take one nitroglycerin
tablet every 5 minutes times three (3), and if
not relieved call 911.

CARDIAC DISORDERS COMPREHENSIVE

EXAMINATION
1. Which population is at a higher risk for dying 6. To what area should the nurse place the
from a myocardial infarction? stethoscope to best auscultate the apical pulse?
1. Caucasian males.
2. Hispanic females.
3. Asian males.
4. African American females.
2. Which preprocedure information should be
taught to the female client having an exercise A B
stress test in the morning? C
1. Wear open-toed shoes to the stress test. D
2. Inform the client not to wear a bra.
3. Do not eat anything for four (4) hours.
4. Take the beta blocker one (1) hour before the
test.
with the client diagnosed with dilated
cardiomyopathy? 1. A
1. Keep the client in the supine position with the 2. B
legs elevated. 3. C
2. Discuss a heart transplant, which is the 4. D
definitive treatment.
7. The telemetry nurse notes a peaked T wave for
3. Prepare the client for coronary artery bypass
the client diagnosed with congestive heart failure.
graft.
Which laboratory data should the nurse assess?
4. Teach the client to take a calcium channel
1. CK-MB.
blocker in the morning.
2. Troponin.
4. Which medical client problem should the nurse 3. BNP.
include in the plan of care for a client diagnosed 4. Potassium.
with cardiomyopathy?
8. The client comes to the emergency department
1. Heart failure.
saying, “I am having a heart attack.” Which
2. Activity intolerance.
question is most pertinent when assessing the
3. Powerlessness.
client?
4. Anticipatory grieving.
1. “Can you describe your chest pain?”
5. The client has an implantable cardioverter 2. “What were you doing when the pain started?”
defibrillator (ICD). Which discharge instructions 3. “Did you have a high-fat meal today?”
should the nurse teach the client? 4. “Does the pain get worse when you lie down?”
1. Do not lift or carry more than 23 kg.
2. Have someone drive the car for the rest of your
life.
3. Carry the cell phone on the opposite side of
the ICD.
4. Avoid using the microwave oven in the home.

9. The client with coronary artery disease is 14. Which laboratory data confirm the diagnosis of
prescribed transdermal nitroglycerin, a coronary congestive heart failure?
vasodilator. Which behavior indicates the client 1. Chest x-ray (CXR).
understands the discharge teaching concerning 2. Liver function tests.
this medication? 3. Blood urea nitrogen (BUN).
1. The client places the medication under the 4. Beta-type natriuretic peptide (BNP).
tongue.
15. What is the priority problem in the client
2. The client removes the old patch before
diagnosed with congestive heart failure?
placing the new.
1. Fluid volume overload.
3. The client applies the patch to a hairy area.
2. Decreased cardiac output.
4. The client changes the patch every 36 hours.
3. Activity intolerance.
10. Which client would most likely be 4. Knowledge deficit.
misdiagnosed for having a myocardial
16. Which data would cause the nurse to question
infarction?
administering digoxin to a client diagnosed with
1. A 55-year-old Caucasian male with crushing
congestive heart failure?
chest pain and diaphoresis.
1. The potassium level is 3.2 mEq/L.
2. A 60-year-old Native American male with an
2. The digoxin level is 1.2 mcg/mL.
elevated troponin level.
3. The client’s apical pulse is 64.
3. A 40-year-old Hispanic female with a normal
4. The client denies yellow haze.
electrocardiogram.
4. An 80-year-old Peruvian female with a normal 17. The nurse is caring for clients on a cardiac floor.
CK-MB at 12 hours. Which client should the nurse assess first?
1. The client with three (3) unifocal PVCs in
11. Which meal would indicate the client
one (1) minute.
understands the discharge teaching concerning
2. The client diagnosed with coronary artery
the recommended diet for coronary artery
disease who wants to ambulate.
disease?
3. The client diagnosed with mitral valve
1. Baked fish, steamed broccoli, and garden
prolapse with an audible S3.
salad.
4. The client diagnosed with pericarditis who is
2. Enchilada dinner with fried rice and refried
in normal sinus rhythm.
beans.
3. Tuna salad sandwich on white bread and 18. The nurse is told in report the client has aortic
whole milk. stenosis. Which anatomical position should the
4. Fried chicken, mashed potatoes, and gravy. nurse auscultate to assess the murmur?
1. Second intercostal space, right sternal notch.
12. The unlicensed assistive personnel (UAP) tells
2. Erb’s point.
the primary nurse that the client diagnosed with
3. Second intercostal space, left sternal notch.
coronary artery disease is having chest pain.
4. Fourth intercostal space, left sternal border.
Which action should the nurse take first?
1. Tell the UAP to go take the client’s vital signs. 19. The nurse is caring for a client who goes into
2. Ask the UAP to have the telemetry nurse read ventricular tachycardia. Which intervention
the strip. should the nurse implement first?

3. Notify the client’s health-care provider. 1. Call a code immediately.
4. Go to the room and assess the client’s chest 2. Assess the client for a pulse.
pain. 3. Begin chest compressions.
4. Continue to monitor the client.
13. Which interventions should the nurse discuss
with the client diagnosed with coronary artery 20. The nurse is assisting with a synchronized
disease? Select all that apply. cardioversion on a client in atrial fibrillation.
1. Instruct the client to stop smoking. When the machine is activated, there is a pause.
2. Encourage the client to exercise three (3) days What action should the nurse take?
a week. 1. Wait until the machine discharges.
3. Teach about coronary vasodilators. 2. Shout “all clear” and don’t touch the bed.
4. Prepare the client for a carotid 3. Make sure the client is all right.
endarterectomy. 4. Increase the joules and redischarge.
5. Eat foods high in monosaturated fats.

21. The client is diagnosed with pericarditis. When 24. The client is three (3) hours post–myocardial
assessing the client, the nurse is unable to infarction. Which data would warrant
auscultate a friction rub. Which action should immediate intervention by the nurse?
the nurse implement? 1. Bilateral peripheral pulses 2+.
1. Notify the health-care provider. 2. The pulse oximeter reading is 96%.
2. Document that the pericarditis has resolved. 3. The urine output is 240 mL in the last four
3. Ask the client to lean forward and listen again. (4) hours.
4. Prepare to insert a unilateral chest tube. 4. Cool, clammy, diaphoretic skin.
22. The nurse assessing the client with pericardial 25. The nurse is transcribing the doctor’s orders for
effusion at 1600 notes the apical pulse is 72 and a client with congestive heart failure. The order
the BP is 138/94. At 1800, the client has neck reads 2.5 mg of Lanoxin daily. Which action
vein distention, the apical pulse is 70, and the should the nurse implement?
BP is 106/94. Which action would the nurse 1. Discuss the order with the health-care
implement first? provider.
1. Stay with the client and use a calm voice. 2. Take the client’s apical pulse rate before
2. Notify the health-care provider immediately. administering.
3. Place the client left lateral recumbent. 3. Check the client’s potassium level before
4. Administer morphine intravenous push slowly. giving the medication.
4. Determine if a digoxin level has been drawn.
23. The client is admitted to the emergency
department, and the nurse suspects a cardiac 26. According to the 2010 American Heart
problem. Which assessment interventions should Association Guidelines, which steps of
the nurse implement? Select all that apply. cardiopulmonary resuscitation for an adult
1. Obtain a midstream urine specimen. suffering from a cardiac arrest should the nurse
2. Attach the telemetry monitor to the client. teach individuals in the community? Rank in
3. Start a saline lock in the right arm. order of performance.
4. Draw a basal metabolic panel (BMP). 1. Place the hands over the lower half of the
5. Request an order for a STAT 12-lead ECG. sternum.
2. Look for obvious signs of breathing.
3. Begin compressions at a ratio of 30:2.
4. Call for and AED immediately.
5. Position the victim on the back.

27. The nurse has received report when the telemetry technician notifies the nurse of the
telemetry readings. Which client should the nurse assess first?
1.
6 seconds
2.
6 seconds
3.
6 seconds
4.
6 seconds

CARDIAC DISORDERS COMPREHENSIVE
EXAMINATION ANSWERS AND RATIONALES
1. 1. Caucasian males have a high rate of coro- 4. Calcium channel blockers are contraindicated
nary artery disease, but they do not delay in clients with dilated cardiomyopathy because
seeking health care as long as some other they interfere with the contractility of the
ethnic groups. The average delay time is five heart.
(5) hours. Content – Medical: Integrated Nursing Process –
2. Hispanic females are at higher risk for diabetes Implementation: Client Needs – Physiological Integrity,
than for dying from a myocardial infarction. Physiological Adaptation: Cognitive Level – Application:
3. Asian males have fewer cardiovascular events, Concept – Perfusion.
which is attributed to their diet, which is high 4. 1. Medical client problems indicate the nurse
in fiber and omega-3 fatty acids. and the physician must collaborate to care
4. African American females are 35% more for the client; the client must have medica-
likely to die from coronary artery disease tions for heart failure.
than any other population. This population 2. The nurse can instruct the client to pace
has significantly higher rates of hyperten- activities and can teach about rest versus activ-
sion and it occurs at a younger age. The ity without a health care provider order.
higher risk of death from an MI is also at- 3. This is a psychosocial client problem that does
tributed to a delay in seeking emergency not require a physician’s order to effectively
care—an average of 11 hours.
care for the client.
Content – Medical: Integrated Nursing Process – 4. Anticipatory grieving involves the nurse ad-
Assessment: Client Needs – Health Promotion and Mainte- dressing issues that will occur based on the
nance: Cognitive Level – Knowledge: Concept – Perfusion.
knowledge of the poor prognosis of this
2. 1. The client should wear firm-fitting, solid disease.
athletic shoes. Content – Medical: Integrated Nursing Process –
2. The client should wear a bra to provide Diagnosis: Client Needs – Physiological Integrity,
adequate support during the exercise. Physiological Adaptation: Cognitive Level – Analysis:
3. NPO decreases the chance of aspiration in Concept – Perfusion.
case of emergency. In addition, if the client 5. 1. Clients should not lift more than 5 to
has just had a meal, the blood supply will 10 pounds because it puts a strain on the
be shunted to the stomach for digestion heart; 23 kg is more than 50 pounds.
and away from the heart, perhaps leading 2. There may be driving restrictions, but the
to an inaccurate test result. client should be able to drive independently.
4. A beta blocker is not taken prior to the stress 3. Cell phones may interfere with the func-
test because it will decrease the pulse rate tioning of the ICD if they are placed too
and blood pressure by direct parasympathetic close to it.
stimulation to the heart.
4. Microwave ovens should not cause problems

Content – Medical: Integrated Nursing Process – with the ICD.
3. 1. Most clients with dilated cardiomyopathy pre- Concept – Perfusion.
fer to sit up with their legs in the dependent 6. 1. This is the best place to auscultate the aortic
position. This position causes pooling of blood valve, the second intercostal space, right
in the periphery and reduces preload. sternal notch.
2. Without a heart transplant, this client 2. This is the best place to auscultate the
will end up in end-stage heart failure. A pulmonic valve, the second intercostal space,
transplant is the only treatment for a client left sternal notch.
with dilated cardiomyopathy. 3. This is the best place to auscultate the tricus-
3. A bypass is the treatment of choice for a c lient pid valve, the third intercostal space, left ster-
with occluded coronary arteries. nal border.
106

4. The best place to auscultate the apical Content – Medical: Integrated Nursing Process –
pulse is over the mitral valve area, which Evaluation: Client Needs – Physiological Integrity, Pharma-
is the fifth intercostal space, midclavicular cological and Parenteral Therapies: Cognitive Level – Analy-
line. sis: Concept – Medication.
Content – Medical: Integrated Nursing Process – 10. 1. Crushing pain and sweating are classic signs
Assessment: Client Needs – Physiological Integrity, of an MI and should not be misdiagnosed.
Reduction of Risk Potential: Cognitive Level – Analysis: 2. An elevated troponin level is a benchmark
Concept – Perfusion. in diagnosing an MI and should not be
7. 1. CK-MB is assessed to determine if the client misdiagnosed.
has had a myocardial infarction. The electri- 3. The clients who are misdiagnosed
cal activity of the heart will not be affected by concerning MIs usually present with atyp-
elevation of this enzyme. ical symptoms. They tend to be female, be
2. Troponin is assessed to determine if the client younger than 55 years old, be members
has had a myocardial infarction. The electri- of a minority group, and have normal
cal activity of the heart will not be affected by electrocardiograms.
elevation of this enzyme. 4. CK-MB may not elevate until up to 24 hours
3. Beta-type natriuretic peptide (BNP) is elevated after onset of chest pain.
in clients with congestive heart failure, but Content – Medical: Integrated Nursing Process –
it does not affect the electrical activity of the Diagnosis: Client Needs – Safe Effective Care
heart. Environment, Management of Care: Cognitive
4. Hyperkalemia will cause a peaked T wave; Level – Knowledge: Concept – Perfusion.
therefore, the nurse should check these 11. 1. The recommended diet for CAD is low
laboratory data. fat, low cholesterol, and high fiber. The
Content – Medical: Integrated Nursing Process – diet described is a diet that is low in fat
Assessment: Client Needs – Safe Effective Care and cholesterol.
Environment, Management of Care: Cognitive 2. This is a diet very high in fat and cholesterol.
Level – Analysis: Concept – Perfusion. 3. The word “salad” implies something has been
8. 1. The chest pain for an MI usually is de- mixed with the tuna, usually mayonnaise,
scribed as an elephant sitting on the chest which is high in fat, but even if the test taker
or a belt squeezing the substernal midchest, did not know this, white bread is low in fiber
often radiating to the jaw or left arm. and whole milk is high in fat.
2. This helps to identify if it is angina (resulting 4. Meats should be baked, broiled, or grilled—
from activity) or MI (not necessarily brought not fried. Gravy is high in fat.
on by activity). Content – Medical: Integrated Nursing Process –
3. Learning about a client’s intake of a high-fat Evaluation: Client Needs – Physiological Integrity,
meal would help the nurse to identify a gall- Basic Care and Comfort: Cognitive Level – Synthesis:
bladder attack. Concept – Nutrition.
4. This is a question the nurse might ask the 12. 1. The client with CAD who is having chest
client with reflux esophagitis. pain is unstable and requires further judg-
Content – Medical: Integrated Nursing Process – ment to determine appropriate actions
Assessment: Client Needs – Safe Effective Care to take, and the UAP does not have that
Environment, Management of Care: Cognitive knowledge.
Level – Analysis: Concept – Assessment. 2. The UAP could go ask the telemetry nurse,
9. 1. The client does not understand how to apply but this is not the first action.
this medication; it is placed on the skin, not 3. The client’s HCP may need to be notified,
under the tongue. but this is not the first intervention.
2. This behavior indicates the client under- 4. Assessment is the first step in the nursing
stands the discharge teaching. process and should be implemented first;
3. The patch needs to be in a nonhairy place so it chest pain is priority.
makes good contact with the skin. Content – Medical: Integrated Nursing Process –
4. The patch should be changed every 12 or Implementation: Client Needs – Safe Effective Care
24 hours but never every two (2) hours. It Environment, Management of Care: Cognitive
takes two (2) hours for the patch to warm up Level – Synthesis: Concept – Assessment.
and begin delivering the optimum dose of
medication.

13. 1. Smoking is the one risk factor that must be 2. This digoxin level is within therapeutic
stopped totally; there is no compromise. range, 0.5 to 2 mcg/mL.
2. Exercising helps develop collateral circu- 3. The nurse would question the medication
lation and decrease anxiety; it also helps if the apical pulse were less than 60.
clients to lose weight. 4. Yellow haze is a sign of digoxin toxicity.
3. Clients with coronary artery disease are Content – Medical: Integrated Nursing Process –
usually prescribed nitroglycerin, which is Assessment: Client Needs – Physiological Integrity,
the treatment of choice for angina. Pharmacological and Parenteral Therapies: Cognitive
4. Carotid endarterectomy is a procedure to re- Level – Analysis: Concept – Medication.
move atherosclerotic plaque from the carotid 17. 1. Three (3) unifocal PVCs in one (1) minute is
arteries, not the coronary arteries. not life threatening.
5. The client should eat polyunsaturated fats, 2. The client wanting to ambulate is not a prior-
not monosaturated fats, to help decrease ity over a client with a physiological problem.
atherosclerosis. 3. An audible S3 indicates the client is devel-
Content – Medical: Integrated Nursing Process – oping left-sided heart failure and needs to
Planning: Client Needs – Physiological Integrity, be assessed immediately.
4. A client in normal sinus rhythm will not be a
priority over someone with a potentially life-
14. 1. The CXR will show an enlarged heart, but threatening situation.
it is not used to confirm the diagnosis of Content – Medical: Integrated Nursing Process –
congestive heart failure. Assessment: Client Needs – Safe Effective Care
2. Liver function tests may be ordered to evalu- Environment, Management of Care: Cognitive
ate the effects of heart failure on the liver, but Level – Analysis: Concept – Assessment.
they do not confirm the diagnosis.
18. 1. The second intercostal space, right ster-
3. The BUN is elevated in heart failure, dehy- nal notch, is the area on the chest where
dration, and renal failure, but it is not used to
the aorta can best be heard opening and
confirm congestive heart failure.
closing.
4. BNP is a hormone released by the heart
2. Erb’s point allows the nurse to hear the
muscle in response to changes in blood
opening and closing of the tricuspid valve.
volume and is used to diagnose and grade
3. The second intercostal space, left sternal
heart failure.
notch, is the area on the chest where the pul-
Content – Medical: Integrated Nursing Process – monic valve can best be heard opening and
Assessment: Client Needs – Physiological Integrity, closing.
Reduction of Risk Potential: Cognitive Level –
4. The fourth intercostal space, left sternal bor-
Analysis: Concept – Perfusion.
der, is another area on the chest that can as-
15. 1. Fluid volume overload is a problem in cli- sess the tricuspid valve.
ents with congestive heart failure, but it is Content – Medical: Integrated Nursing Process –
not priority because, if the cardiac output Assessment: Client Needs – Physiological Integrity,
is improved, then the kidneys are perfused, Reduction of Risk Potential: Cognitive Level –
which leads to elimination of excess fluid Analysis: Concept – Perfusion.
from the body. 19. 1. The nurse should call a code if the client does
2. Decreased cardiac output is responsible not have vital signs.
for all the signs/symptoms associated with 2. The nurse must first determine if the
CHF and eventually causes death, which is client has a pulse. Pulseless ventricular
why it is the priority problem. tachycardia is treated as ventricular fibril-
3. Activity intolerance alters quality of life, but
lation. Stable ventricular tachycardia is
it is not life threatening. treated with medications.
4. Knowledge deficit is important, but it is not 3. Chest compression is only done if the client is
priority over a physiological problem. not breathing and has no pulse.
Content – Medical: Integrated Nursing Process – 4. Ventricular tachycardia is a potentially life-
Diagnosis: Client Needs – Physiological Integrity, threatening dysrhythmia and needs to be
Physiological Adaptation: Cognitive Level – Analysis:
treated immediately.
16. 1. This potassium level is below normal levels; Implementation: Client Needs – Safe Effective Care
hypokalemia can potentiate digoxin toxicity Environment, Management of Care: Cognitive
and lead to cardiac dysrhythmias. Level – Synthesis: Concept – Perfusion.

20. 1. Cardioversion involves the delivery of a 4. Morphine would be given to a client with
timed electrical current. The electrical pain from myocardial infarction; it is not a
impulse discharges during ventricular treatment option for cardiac tamponade.
depolarization and, therefore, there might Content – Medical: Integrated Nursing Process –
be a short delay. The nurse should wait Implementation: Client Needs – Safe Effective Care
until it discharges. Environment, Management of Care: Cognitive Level –
2. Calling “all clear” and not touching the bed Synthesis: Concept – Perfusion.
should be done prior to activating the ma- 23. 1. A midstream urine specimen is ordered for a
chine to discharge the electrical current. client with a possible urinary tract infection,
3. A pause is an expected event, and asking if not for a client with cardiac problems.
the client is all right may worry the client 2. Anytime a nurse suspects cardiac prob-
unnecessarily. lems, the electrical conductivity of the
4. Increasing joules and redischarging is imple- heart should be assessed.
mented during defibrillation, not during syn- 3. Emergency medications for heart prob-
chronized cardioversion. lems are primarily administered intra-
Content – Medical: Integrated Nursing Process – venously, so starting a saline lock in the
Implementation: Client Needs – Safe Effective Care right arm is appropriate.
Environment, Management of Care: Cognitive
4. This serum blood test is not specific to assess
Level – Application: Concept – Perfusion.
cardiac problems. A BMP evaluates potas-
21. 1. These assessment data are not life threaten- sium, sodium, glucose, and more.
ing and do not warrant notifying the HCP. 5. A 12-lead ECG evaluates the electrical
2. The nurse should attempt to hear the friction conductivity of the heart from all planes.
rub in multiple ways before documenting that Content – Medical: Integrated Nursing Process –
it is not heard. The nurse does not determine Implementation: Client Needs – Safe Effective Care
if pericarditis has resolved. Environment, Management of Care: Cognitive
3. Having the client lean forward and to the Level – Analysis: Concept – Assessment.
left uses gravity to force the heart nearer
24. 1. This pulse indicates the heart is pumping ad-
to the chest wall, which allows the friction
equately. Normal pulses should be 2+ to 3+.
rub to be heard.
2. A pulse oximeter reading of greater than 93%
4. Chest tubes are not the treatment of choice indicates the heart is perfusing the periphery.
for not hearing a friction rub. 3. An output of 30 mL/hr indicates the heart is
Content – Medical: Integrated Nursing Process – perfusing the kidneys adequately.
Implementation: Client Needs – Physiological 4. Cold, clammy skin is an indicator of car-
Integrity, Reduction of Risk Potential: Cognitive
diogenic shock, which is a complication of
Level – Application: Concept – Perfusion.
MI and warrants immediate intervention.
22. 1. This is a medical emergency; the nurse Content – Medical: Integrated Nursing Process –
should stay with the client, keep him calm, Assessment: Client Needs – Physiological Integrity,
and call the nurses’ station to notify the Reduction of Risk Potential: Cognitive Level – Synthesis:
health-care provider. Cardiac output de- Concept – Perfusion.
clines with each contraction as the peri- 25. 1. This dosage is 10 times the normal dose
cardial sac constricts the myocardium. for a client with CHF. This dose is poten-
2. The client’s signs/symptoms would make the tially lethal.
nurse suspect cardiac tamponade, a medical 2. No other action can be taken because of the
emergency. The pulse pressure is narrowing, incorrect dose.
and the client is experiencing severe rising 3. No other action can be taken because of the
central venous pressure as evidenced by neck incorrect dose.
vein distention. Notifying the health-care 4. No other action can be taken because of the
provider is important, but the nurse should incorrect dose.
stay with the client first.
3. A left lateral recumbent position is used when
Implementation: Client Needs – Physiological Integrity,
administering enemas. Pharmacological and Parenteral Therapies: Cognitive
Level – Application: Concept – Medication.

26. In order of performance: 5, 2, 4, 1, 3 27. 1. Atrial fibrillation is not life threatening.

5. The victim is positioned on the back for 2. Unifocal PVCs are common in most clients
assessment and for the rescuer to be able and are not life threatening. Up to six (6)
to begin cardiopulmonary resuscitation. per minute may occur before the nurse must
2. Although we now perform a quick look to intervene.
determine if the victim is breathing there 3. This is complete heart block with brady-
is no longer a “look, listen, feel” step. The cardia, a potentially life-threatening situ-
victim may not be breathing at all or may ation. The nurse should assess this client
be having agonal respirations. first and make interventions accordingly.
4. For adults the rescuer should immedi- 4. Sinus tachycardia may occur for different
ately call for an AED or 911. Research reasons, such as ambulating to the bathroom,
has proven the faster that defibrillation is fever, or anemia. This is not life threatening.
performed the better the chance of sur- Content – Medical: Integrated Nursing Process –
vival for the victim. Assessment: Client Needs – Physiological Integrity,
1. Compressions are initiated immediately Physiological Adaptation: Cognitive Level – Synthesis:
because the victim will have some residual Concept – Perfusion.
oxygen in the lungs. Breathing is not
initiated unless there is a barrier device
available.
3. The compression rate is 30:2.
Content – Fundamentals: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Knowledge: Concept – Perfusion.

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Cardiac Disorders

If you have knowledge, let others light their candles in it.

Telemetry International normalized ratio (INR)

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9. The nurse and an unlicensed assistive personnel Angina/Myocardial Infarction

12. The nurse has written an outcome goal

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movements. response by the nurse?

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200 joules. nurse implement?

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1. Explain the importance of tapering off the

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3. If one nitroglycerin tablet does not work in 10

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79. The client’s telemetry reading is below.

1. Furosemide IVP to a client with a potassium

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who is complaining of being constipated. (DI).

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heart with adequate output. An audible S3

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ment, Management of Care: Cognitive Level – Synthesis: Application: Concept – Perfusion.

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first intervention. risk factors.

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and the UAP should not be told to stop

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chest pain is relieved. Content – Medical: Integrated Nursing Process –

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stenosis. be replaced frequently; this is a disadvan-

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TEST-TAKING HINT: This is a knowledge-based levels are monitored for heparin.

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63. 1. A sore throat in the last month would not

2. Fatigue and arthralgias are nonspecific

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new development of the clinical manifesta-

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kidneys; it is not a perfusion issue.

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CARDIAC DISORDERS COMPREHENSIVE

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the strip. should the nurse implement first?

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