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CARDIOVASCULAR (EXAMAINATION)
1. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours
before the procedure and for 48 hours after the procedure?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)
4.
Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac
catheterization because of the injection of contrast medium during the procedure. If the contrast
medium affects kidney function, with metformin in the system, the client would be at increased risk for
lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before
and 48 hours after cardiac catheterization.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Planning
Content Area: Adult Health: Cardiovascular
Strategy(s): Comparable or Alike Options
Priority Concepts: Perfusion, Safety
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular.
The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64
beats/minute. Which would be a correct interpretation based on these characteristics?
1.Sinus bradycardia
2.Sick sinus syndrome
3.Normal sinus rhythm
4.First-degree heart block
3.
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The
PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second,
respectively.
Integrated Process: Nursing Process: Assessment
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no
electrocardiographic complexes on the screen. Which is the priority action of the nurse?
1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.
3.
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode

displacement. Accurate assessment of the client and equipment is necessary to determine the cause
and identify the appropriate intervention. The remaining options are secondary to client assessment.
Cognitive Ability: Applying
Integrated Process: Nursing Process: Implementation
Strategy(s): Strategic Words, Steps of the Nursing Process
A client is having frequent premature ventricular contractions. The nurse should place priority on
assessment of which item?
1.Sensation of palpitations
2.Causative factors, such as caffeine
3.Precipitating factors, such as infection
4.Blood pressure and oxygen saturation
4.
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to
monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to
decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature
ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of
physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine,
or alcohol.

Strategy(s): Strategic Words, ABCs—Airway, Breathing, Circulation
The nurse is evaluating a client's response to cardioversion. Which observation would be of highest
priority to the nurse?
1.Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2.
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
Cognitive Ability: Evaluating
Integrated Process: Nursing Process: Evaluation
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-
defibrillator. The nurse immediately would assess which item based on priority?
1.Anxiety level of the client and family
2.Presence of a Medic-Alert card for the client to carry
3.Knowledge of restrictions of postdischarge physical activity
4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
4.
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator
needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the
nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and
the number of shocks it is programmed to deliver. The remaining options are also nursing interventions
but are not the priority.

Strategy(s): Strategic Words, Maslow's Hierarchy of Needs Theory
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval
is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How
should the nurse correctly interpret this rhythm?
1.Sinus dysrhythmia
2.Sinus tachycardia
3.Sinus bradycardia
2.
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and
normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia,
the atrial and ventricular rates are greater than 100 beats/minute.
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4
hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes
redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse
correctly interpret the client's neurovascular status?
1.The neurovascular status is normal because of increased blood flow through the leg.
2.The neurovascular status is moderately impaired, and the surgeon should be called.
3.The neurovascular status is slightly deteriorating and should be monitored for another hour.
4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.
1.
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical
extremity because of increased blood flow. The remaining options are incorrect interpretations.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac
tamponade. Which observation would indicate that the procedure was unsuccessful?
1.Rising blood pressure
2.Clearly audible heart sounds
3.Client expressions of relief
4.Rising central venous pressure
4.
Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected.
The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.
A client with angina complains that the anginal pain is prolonged and severe and occurs at the same
time each day, most often at rest in the absence of precipitating factors. How would the nurse best
describe this type of anginal pain?
1.Stable angina
2.Variant angina
3.Unstable angina
4.Nonanginal pain
2.
Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day,
most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets.
Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of
myocardial infarction.
Cognitive Ability: Understanding

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which
assessment finding indicates the presence of this complication?
1.Flat neck veins
2.A pulse rate of 60 beats/min
3.Muffled or distant heart sounds
4.Wheezing on auscultation of the lungs
3.
Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart
sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by
pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Bradycardia is not a sign
of cardiac tamponade.
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home
care management and self-care management. Which statement, if made by the client, indicates a need
for further instruction?
1."I need to be sure not to go barefoot around the house."
2."If I cut my toenails, I need to be sure that I cut them straight across."
3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."
4."I need to be sure that I elevate my leg above my heart level for at least an hour every day."
4.
Foot care instructions for the client with peripheral arterial disease are the same as those for a client
with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the
level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also
present. The client statements in options 1, 2, and 3 are correct statements.

Integrated Process: Teaching and Learning
Strategy(s): Strategic Words, Negative Event Query, Subject
Priority Concepts: Client Education, Tissue Integrity
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The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium
items to be avoided. The nurse instructs the client to avoid consuming which item?
1.Bananas
2.Broccoli
3.Antacids
4.Cantaloupe
3.
The sodium level can increase with the use of several types of products, including toothpaste and
mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and
softened water and mineral water. Clients are instructed to read labels for sodium content. Water that
is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and
vegetables are low in sodium.
Strategy(s): Subject, Comparable or Alike Options
Priority Concepts: Client Education, Nutrition
The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan
to provide which instruction to the client?
1.Use nail polish to protect the nail beds from injury.
2.Stop smoking because it causes cutaneous vasospasm.
3.Wear gloves for all activities involving use of both hands.
4.Always wear warm clothing even in warm climates to prevent vasoconstriction.
2.
Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the

extremities. Smoking cessation is one of the most important lifestyle changes that the client must make.
The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in
stopping smoking. The nurse needs to provide information to the client about smoking cessation
programs available in the community. Options 1 and 4 are incorrect. It is not necessary to wear gloves
for all activities.
Strategy(s): Closed-ended Word
Priority Concepts: Client Education, Perfusion
The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred
over the varicosities as a result of secondary infection. Which is a priority intervention?
1.Keep the legs aligned with the heart.
2.Elevate the legs higher than the heart.
3.Clean the skin with alcohol every hour.
4.Position the client onto the side every shift.
2.
In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the
return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be
used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority
intervention.
Strategy(s): Strategic Words
Priority Concepts: Infection, Perfusion
The nurse in the medical unit is reviewing the laboratory test results for a client who has been
transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was
performed while the client was in the intensive care unit. The nurse determines that this test was
performed to assist in diagnosing which condition?
1.Heart failure
2.Atrial fibrillation
3.Myocardial infarction
4.Ventricular tachycardia
3.
Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of
myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a
myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial
fibrillation.
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse
notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The
nurse should next assess the client for which finding?
1.Hypotension
2.Flat neck veins
3.Complaints of nausea
4.Complaints of headache
1.
The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk
for low cardiac output owing to loss of atrial kick. The nurse assesses the client for palpitations, chest
pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of
breath, and distended neck veins.
Integrated Process: Nursing Process:
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which
assessment component would elicit specific information regarding the client's left-sided heart function?
1.Listening to lung sounds
2.Monitoring for organomegaly
3.Assessing for jugular vein distention
4.Assessing for peripheral and sacral edema

1.
The client with heart failure may present with different symptoms, depending on whether the right or
the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and
organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute
an accurate indicator of left-sided heart function.
The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of
myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which
interpretation about this finding?
1.A normal finding
2.Indicative of atrial flutter
3.Indicative of atrial fibrillation
4.Indicative of impending reinfarction
1.
The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the
ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of
angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the
disease process. The client continually changes the subject during the teaching session. The nurse
interprets that this client's behavior is most likely related to which problem?
1.Anxiety related to the need to make lifestyle changes
2.Boredom resulting from having already learned the material

3.An attempt to ignore or deny the need to make lifestyle changes
4.Lack of understanding of the material provided at the teaching session and embarrassment about
asking questions
3.
Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by
refusal to discuss what has happened. Denial is a common early reaction associated with chest
discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of
sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to
interpret the client's behavior as boredom or as either understanding or not understanding the material
provided at the teaching session.
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Analysis
Priority Concepts: Client Education, Coping
A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On
removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the
surrounding tissue is cool to the touch. The nurse should document that these findings identify which
type of ulcer?
1.A stage 1 ulcer
2.A vascular ulcer
3.An arterial ulcer
4.A venous stasis ulcer
3.
Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such
as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply
of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous
stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of
ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of
venous congestion.
Integrated Process: Communication and Documentation

Priority Concepts: Clinical Judgment, Tissue Integrity
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis
of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health
care provider will most likely prescribe which option?
1.Maintain bed rest.
2.Maintain the affected leg in a dependent position.
3.Administer an opioid analgesic every 4 hours around the clock.
4.Apply cool packs to the affected leg for 20 minutes every 4 hours.
1.
Standard management for the client with DVT includes bed rest; limb elevation; relief of discomfort with
warm, moist heat; and analgesics as needed. Ambulation is contraindicated because such activity can
cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve
pain, and pain normally is relieved with acetaminophen (Tylenol).
Strategy(s): Subject, Strategic Words
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A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse
to describe the procedure. Which response should the nurse make?
1."It involves tying off the veins so that circulation is redirected in another area."
2."It involves surgically removing the varicosity, so anesthesia will be required."
3."It involves tying off the veins to prevent sluggishness of blood from occurring."
4."It involves injecting an agent into the vein to damage the vein wall and close it off."
4.
Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and
causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel,
distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This
procedure involves tying off the varicose vein and large tributaries and then removing the vein with the
use of a hook and wires applied through multiple small incisions in the leg. Other treatments include the
application of radiofrequency (RF) energy, in which the vein is heated from the inside by the RF energy
and shrinks; collateral veins nearby take over. Laser treatment is another alternative to surgery; in this
treatment a laser fiber is used to heat and close the main vessel that is contributing to the varicosity.
A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping
procedure was performed, she has been experiencing a sensation as though the affected leg is falling
asleep. The nurse should make which response to the client?
1."Apply warm packs to the leg."
2."Keep the leg elevated as much as possible."
3."Contact your health care provider right away to report this problem."
4."This normally occurs after surgery and will subside when the edema goes down."
3.
A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate
temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run
close together, and damage to the nerve will produce paresthesias. Options 1, 2, and 4 are inaccurate
responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the
insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential
complications include bruising, tightness along the vein, recanalization (reopening of the vein), and
paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or
phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to
destroy the varices and then removes the pieces via aspiration.
The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client
is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse
should provide which information to the client?
1.Oxygen has a calming effect.

2.Oxygen will prevent the development of any thrombus.
3.Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle.
4.The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.
4.
The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated
by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet
the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus
formation and does not directly calm the client.
A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the
nursing unit after the procedure, and the nurse provides instructions to the client regarding home care
measures. Which statement, if made by the client, indicates an understanding of the instructions?
1."I need to cut down on cigarette smoking."
2."I am so relieved that my heart is repaired."
3."I need to adhere to my dietary restrictions."
4."I am so relieved that I can eat anything I want to now."
3.
After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must
be followed. Making the recommended dietary and lifestyle changes will assist in preventing further
atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are
not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in
completing the diet menu. Which beverage should the nurse instruct the client to select from the menu?
1.Tea
2.Cola
3.Coffee
4.Raspberry juice
4.
A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can
produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain
caffeine and need to be avoided in the client with MI.
Client Needs: Health Promotion and Maintenance
The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who
takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The
nurse should immediately ask the client which question?
1."Where is the pain located?"
2."Are you having any nausea?"
3."Are you allergic to any medications?"
4."Do you have your nitroglycerin with you?"
1.
If a client complains of chest pain, the initial assessment question would be to ask the client about the
pain intensity, location, duration, and quality. Although options 2, 3, and 4 all may be components of the
assessment, none of these questions would be the initial assessment question with this client.
Strategy(s): Strategic Words, Subject

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by
the client indicates an understanding of the dietary instructions?
1."I'll need to become a strict vegetarian."
2."I should use polyunsaturated oils in my diet."
3."I need to substitute eggs and whole milk for meat."
4."I should eliminate all cholesterol and fat from my diet."
2.
The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as
eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use
of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to
eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
A client is admitted to the visiting nurse service for assessment and follow-up after being discharged
from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary
restrictions required with HF. Which statement by the client indicates that further teaching is needed?
1."I'm not supposed to eat cold cuts."
2."I can have most fresh fruits and vegetables."
3."I'm going to weigh myself daily to be sure I don't gain too much fluid."
4."I'm going to have a ham and cheese sandwich and potato chips for lunch."
4.
When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is
through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily
weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and
vegetables are low in sodium.
Strategy(s): Strategic Words, Negative Event Query

Priority Concepts: Client Education, Health Promotion
The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of
118/78 mm Hg, total cholesterol level of 190 mg/dL, and fasting blood glucose level of 184 mg/dL. The
nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease
(CAD)?
1.Age
2.Hypertension
3.Hyperlipidemia
4.Glucose intolerance
4.
Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of
CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors to
CAD. Age greater than 40 years is a nonmodifiable risk factor. The nurse places priority on risk factors
that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating
glucose intolerance as the priority risk factor.
Priority Concepts: Clinical Judgment, Health Promotion
The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage
independently at home after discharge. Which statement by the client is the strongest indicator of the
potential for difficulty after discharge?
1."I need to start exercising more to improve my health."
2."I will be sure to keep my appointment with the cardiologist."
3."I don't have anyone to help me with doing heavy housework at home."
4."I think I have a good understanding of what all my medications are for."
3.
To ensure the best outcome, clients should be able to comply with instructions related to activity, diet,
medications, and follow-up health care on discharge from the hospital after an MI. All of the options
except the correct option indicate that the client will be successful in these areas.

Priority Concepts: Functional Ability, Health Promotion
The home care nurse has taught a client with a problem of inadequate cardiac output about helpful
lifestyle adaptations to promote health. Which statement by the client best demonstrates an
understanding of the information provided?
1."I will eat enough daily fiber to prevent straining at stool."
2."I will try to exercise vigorously to strengthen my heart muscle."
3."I will drink 3000 to 3500 mL of fluid daily to promote good kidney function."
4."Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."
1.
Standard home care instructions for a client with this problem include, among others, lifestyle changes
such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting
a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance.
Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.
A client has been experiencing difficulty with completion of daily activities because of underlying
cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which
observation by the nurse best indicates client progress in meeting goals for this problem?
1.Ambulates 10 feet farther each day
2.Verbalizes the benefits of increasing activity
3.Chooses a healthy diet that meets caloric needs
4.Sleeps without awakening throughout the night
1.
Each of the options indicates a positive outcome on the part of the client. Both options 2 and the correct
one relate to the client problem of difficulty with completion of daily activities. However, the question
asks about progress. The correct option is more action-oriented and therefore is the better choice.
Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake.
Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.
The health care provider has written a prescription for a client to have an echocardiogram. Which action
should the nurse take to prepare the client for the procedure?
1.Questions the client about allergies to iodine or shellfish
2.Has the client sign an informed consent form for an invasive procedure
3.Tells the client that the procedure is painless and takes 30 to 60 minutes
4.Keeps the client on nothing-by-mouth (NPO) status for 2 hours before the procedure
3.
Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It

commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60
minutes while the procedure is being performed. It is important to provide adequate information to
eliminate unnecessary worry on the part of the client.
Priority Concepts: Caregiving, Client Education
A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which
instruction should the nurse plan to provide to the client about this procedure?
1.Eat breakfast just before the procedure.
2.Wear firm, rigid shoes, such as workboots.
3.Wear loose clothing with a shirt that buttons in front.
4.Avoid cigarettes for 30 minutes before the procedure.
3.
The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead
placement is enhanced if the client wears a shirt that buttons in the front. The client should receive
nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client should wear
rubber-soled, supportive shoes, such as athletic training shoes. The client should avoid smoking, alcohol,
and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with
the potential for a false-positive result.
A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The
nurse places highest priority on telling the client to report which sensation during the procedure?
1.Chest pain
2.Urge to cough
3.Warm, flushed feeling
4.Pressure at the insertion site
1.
The client is taught to report chest pain or any unusual sensations immediately. The client also is told
that he or she may be asked to cough or breathe deeply from time to time during the procedure. The
client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a
local anesthetic is used, the client is expected to feel pressure at the insertion site.
A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to
teach the client to do to manage or prevent recurrent symptoms after discharge?
1.Sleep with the head of bed flat.
2.Weigh himself or herself on a daily basis.
3.Take a double dose of the diuretic if peripheral edema is noted.
4.Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.
2.
The client can best determine fluid status at home by weighing himself or herself on a daily basis.
Increases of 2 to 3 lb in a short period are reported to the health care provider (HCP). The client should
sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the
interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic
circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify
medication dosages without consulting the HCP.
Priority Concepts: Fluid and Electrolyte Balance, Perfusion
A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides
instructions to the client. Which client statement indicates an understanding of the instructions?
1."It will really hurt when the catheter is first put in."
2."I will receive general anesthesia for the procedure."
3."I will have to go to the operating room for this procedure."
4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."
4.
It is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic
is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other
preprocedure teaching points include the fact that the procedure is done in a darkened cardiac
catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take
1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.
A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse
caring for the client uses which item as the best means to monitor respiratory status on an ongoing
basis?
1. Apnea monitor
2.Oxygen flowmeter
3.Telemetry cardiac monitor
4.Oxygen saturation monitor
4.
Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an
oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea
episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the
setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.
Priority Concepts: Clinical Judgment, Gas Exchange
A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two
flights of stairs or after walking four blocks. What type of angina should the nurse determine that the
client is experiencing?
1.Stable
2.Variant
3.Unstable
4.Intractable
1.
Stable angina is triggered by a predictable amount of effort or emotion. Variant angina is triggered by
coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early
in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion
and may occur at night; the attacks increase in number, duration, and severity over time. Intractable
angina is chronic and incapacitating and is refractory to medical therapy.
Priority Concepts: Pain, Perfusion
A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest
pain. The nurse knows that which ECG finding would be an indication of first-degree heart block?
1.Presence of Q waves
2.Tall, peaked T waves
3.Prolonged PR interval
4.Widened QRS complex
3.
A prolonged PR interval indicates first-degree heart block. The development of Q waves indicates
myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates
a delay in intraventricular conduction, such as bundle branch block. An ECG taken during a pain episode
is intended to capture ischemic changes, which also include ST-segment elevation or depression.
The nurse is teaching the client with angina pectoris about disease management and lifestyle changes
that are necessary to control disease progression. Which statement by the client indicates a need for
further teaching?
1."I will avoid using table salt with meals."
2."It is best to exercise once a week for 1 hour."
3."I will take nitroglycerin whenever chest discomfort begins."
4."I will use muscle relaxation to cope with stressful situations."
2.
Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart
rate. Other healthful habits include limiting salt and fat in the diet and using stress management
techniques. The client also should be taught to take nitroglycerin before any activity that previously
caused the pain and to take the medication at the first sign of chest discomfort.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant)
angina. What should the nurse plan to teach the client about this type of angina?
1.It is most effectively managed by β-blocking agents.
2.It has the same risk factors as stable and unstable angina.
3.It can be controlled with a low-sodium, high-potassium diet.
4.Generally it is treated with calcium-channel-blocking agents
4.
Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium-channel
blockers. β-Blockers are contraindicated because they may actually worsen the spasm. The risk factors
are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not
specifically indicated.
The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The
nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of
what assessment finding?
1.The client is not experiencing dyspnea.
2.The client is not experiencing nausea or vomiting.
3.The pain has not been relieved by rest and nitroglycerin tablets.
4.The client says the pain began while she was trying to open a stuck dresser drawer.
3.
The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine
sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is
precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest
and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically
begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated
symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety).

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the
general medical unit. What activity level should the nurse encourage for the client immediately after
transfer?
1.Ad lib activities as tolerated
2.Strict bed rest for 24 hours after transfer
3.Bathroom privileges and self-care activities
4.Unsupervised hallway ambulation for distances up to 200 feet
3.
On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care
activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially
harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client
should ambulate with supervision in the hall for brief distances, with the distances being gradually
increased to 50, 100, and 200 feet.
Strategy(s): Strategic Words, Comparable or Alike Options
Priority Concepts: Functional Ability, Perfusion
A client with no history of heart disease has experienced acute myocardial infarction and has been given
thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse
identify as the most likely indicator that the client is experiencing complications of this therapy?
1.Tarry stools
2.Nausea and vomiting
3.Orange-colored urine
4.Decreased urine output
1.
Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for
obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the
gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for
occult blood. The correct option is the only one that indicates the presence of blood.

Priority Concepts: Clinical Judgment, Clotting
The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD).
Which statement should the nurse make to try to motivate the client to quit smoking?
1."None of the cardiovascular effects are reversible, but quitting might prevent lung cancer."
2."Because most of the damage has already been done, it will be all right to cut down a little at a time."
3."If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year."
4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4
years."
4.
The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three
to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked.
In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental
smoke) substantially reduce blood flow in the coronary arteries. Options 1, 2, and 3 are incorrect.
Priority Concepts: Health Promotion, Motivation
A client has experienced an episode of pulmonary edema. The nurse determines that the client's
respiratory status is improving after this episode if which breath sounds are noted?
1.Rhonchi
2.Wheezes
3.Crackles in the bases
4.Crackles throughout the lung fields
3.
Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production
of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli
decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of
the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs
reveals crackles throughout the lung fields.
Priority Concepts: Clinical Judgment, Gas Exchange
A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In
explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily
responsible for the symptoms?
1.Left atrium
2.Right atrium
3.Left ventricle
4.Right ventricle
3.
Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke
volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left
ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers
that are primarily responsible for this disease process although these chambers may become affected as
the disease becomes more chronic.
A client has experienced a myocardial infarction. The nurse plans care for the client, knowing that the
person's chest pain is caused by tissue hypoxia in which layer of the heart?
1.Myocardium
2.Endocardium
3.Parietal pericardium
4.Visceral pericardium
1.
The myocardial layer of the heart is damaged when a client experiences a myocardial infarction. This is
the middle layer that contains the striated muscle fibers responsible for the contractile force of the
heart. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral
pericardium are outer layers that protect the heart from injury and infection.
A client is admitted to the hospital with a diagnosis of mitral stenosis. The narrowing of this valve will
impede circulation of blood through which structures?
1.Left ventricle to aorta
2.Left atrium to left ventricle
3.Right atrium to right ventricle
4.Right ventricle to pulmonary artery
2.
The mitral valve separates the left atrium from the left ventricle. Options 1, 3, and 4 describe the aortic,
tricuspid, and pulmonic valves, respectively.
A client is admitted to the hospital with a diagnosis of aortic regurgitation. The nurse plans care for the
client, knowing that the failure of the aortic valve to close completely allows blood to flow retrograde
through which structures?
1.Aorta to left ventricle
2.Left ventricle to left atrium
3.Right ventricle to right atrium
4.Pulmonary artery to right ventricle
1.
The aortic valve separates the aorta from the left ventricle. Options 2, 3, and 4 describe the mitral,
tricuspid, and pulmonic valves, respectively.
A hospitalized client is experiencing a decrease in blood pressure. The nurse plans care for the client,
knowing that this change will have which primary effect on his or her heart?
1.Decreased heart rate
2.Increased contractility
3.Decreased myocardial blood flow
4.Increased resistance to electrical stimulation
3.
The primary effect of a decrease in blood pressure is reduced blood flow to the myocardium. This in turn
decreases oxygenation of the cardiac tissue. Cardiac tissue is likely to become more excitable or irritable
in the presence of hypoxia. Correspondingly, the heart rate is likely to increase, not decrease, in
response to this change. The effects of tissue ischemia lead to decreased contractility over time.
A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes
action, knowing that this level could ultimately lead to which complication?
1.Stroke
2.Cardiac arrest
3.High blood pressure
4.Urinary stone formation
2.
The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular
dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for
contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move
back during repolarization. Depolarization is responsible for cardiac contraction. Options 1 and 3 are
unrelated to calcium levels. Elevated calcium levels can lead to urinary stone formation. The nurse
would take action and contact the health care provider when a calcium level is abnormal.
A nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental
concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart
responsible for initiating electrical impulses is which site?
1.Bundle of His
2.Purkinje fibers
3.Sinoatrial (SA) node
4.Atrioventricular (AV) node
3.
The SA node is responsible for initiating electrical impulses that are conducted through the heart. The
impulse leaves the SA node and travels down through internodal and interatrial pathways to the AV
node. From there, impulses travel through the bundle of His to the right and left bundle branches and
then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction
system. The ability of this specialized tissue to generate its own impulses is called automaticity.
A nursing instructor asks a nursing student to describe the structure and function of the coronary
arteries. Which response by the student indicates a need for further research on the anatomy and
physiology of the heart?
1."The coronary arteries branch from the aorta."

2."The coronary arteries supply the heart muscle with blood."
3."The left coronary artery provides blood for the left atrium and the left ventricle."
4."The left coronary artery supplies the right atrium and right ventricle with blood."
4.
The left coronary artery divides into the anterior descending artery and the circumflex artery, providing
blood for the left atrium and left ventricle. The right coronary artery supplies the right atrium and right
ventricle. Options 1, 2, and 3 are correct.
A nurse is assigned to the care of a client with a cardiac disorder and is told that the client has an
alteration in cardiac output. The nurse plans care with the understanding that the heart normally sends
out how many liters of blood per minute to the body?
1.2 L/min
2.5 L/min
3.10 L/min
4.15 L/min
2.
The cardiac cycle consists of contraction and relaxation of the heart muscle. The heart normally sends
out about 5 L of blood every minute to the body. Therefore, options 1, 3, and 4 are incorrect.
A nurse is caring for a client who has lost a significant amount of blood as a result of complications of a
surgical procedure. The nurse understands that which client assessment will provide the earliest
indication of new decreases in fluid volume?
1.Pulse rate
2.Blood pressure (BP)
3.Assessment for edema
4.Lung auscultation for crackles
1.
The cardiac output is determined by the volume of the circulating blood, the pumping action of the
heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an
increase in the pulse rate. Options 3 and 4 indicate an increase in fluid volume. Although the BP will
decrease, it is not the earliest indicator.
A client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over
both carotid arteries simultaneously. A nurse exercising nearby is correct when the nurse cautions him
to check the pulse on only one side, primarily for which reason?
1.It is unnecessary to use both hands.
2.The client could occlude the trachea.
3.The heart rate and blood pressure could drop.
4.Feeling dual pulsations may lead to an incorrect measurement.
3.
Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the
baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In
addition, the manual pressure could interfere with the flow of blood to the brain, causing possible
dizziness and syncope. Although the information in options 1, 2, and 4 may be correct, these are not the
primary reasons.

A nursing student who is researching a medication at the nursing station asks the registered nurse (RN)
what an α1-adrenergic receptor is. The RN responds by telling the student that these receptors are
found primarily in which peripheral vascular structures and produce which actions?
1.The peripheral arteries and veins, and when stimulated cause vasoconstriction
2.Arterial and bronchial walls, and when stimulated cause vasodilation and bronchodilation
3.The heart, and when stimulated cause an increase in heart rate, atrioventricular (AV) node conduction,
and contractility
4.Several tissues, and when stimulated cause contraction of smooth muscle, inhibition of lipolysis, and
promotion of platelet aggregation
1.
Found in the peripheral arteries and veins, α1-adrenergic receptors cause a powerful vasoconstriction
when stimulated. Options 2, 3, and 4 describe β1-, β2-, and α2-adrenergic receptors, respectively.
Priority Concepts: Leadership, Perfusion
A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin
(Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about
this information?
1.Normal, because of the client's age
2.Abnormal, requiring further assessment
3.Normal, as a result of the effects of digoxin
4.Normal, because this is the reason the client is receiving digoxin
2.
The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60
beats/min, the nurse would not administer the digoxin and would report the finding to the health care
provider. Digoxin increases the strength and contraction of the heart; it is not used to treat low heart
rates. If a low heart rate is noted in a client taking digoxin, the medication is withheld and the health
care provider is notified. Options 1, 3, and 4 are incorrect interpretations because the heart rate of 52
beats/min is not normal.

A client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding"
when he is exercising vigorously. In formulating a response, the nurse understands that this effect
occurs because of the client's primary need for which increased cardiac response?
1.Pulse rate
2.Cardiac index
3.Cardiac output
4.Stroke volume
3.
The client's symptoms are the direct result of the body's attempt to meet the metabolic demands
generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital
organs of the body. With exercise, these demands increase, and the heart must beat faster (increased
heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number
used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting
the cardiac output for body surface area.
Strategy(s): Strategic Words, Subject, Umbrella Option
A nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family.
The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that
supplies the anterior wall of the left ventricle. The nurse determines that the HCP is referring to which
arteries?
1.Circumflex coronary artery
2.Right coronary artery (RCA)
3.Posterior descending coronary artery (PDA)
4.Left anterior descending coronary artery (LAD)
4.
The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and
a few other structures. The circumflex coronary artery bifurcates from the left coronary artery and
supplies the left atrium and the lateral wall of the left ventricle. The RCA supplies the right side of the
heart, including the right atrium and right ventricle. The PDA supplies the posterior wall of the heart.
A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse
anticipates that the client will exhibit which findings on assessment of vital signs?
1.Increased heart rate and increased blood pressure
2.Increased heart rate and decreased blood pressure
3.Decreased heart rate and increased blood pressure
4.Decreased heart rate and decreased blood pressure
4.
Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body
are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases,
resulting in decreased heart rate and blood pressure. Therefore, options 1, 2, and 3 are incorrect.
Priority Concepts: Clinical Judgment, Thermoregulation
A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to
ensure having a bowel movement. The nurse's response incorporates the information that bearing
down or straining would trigger which physical response?
1.Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility
2.Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility
3.Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility
4.Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility
1.
Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the
vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic
nervous system has the opposite effect. These two branches of the autonomic nervous system oppose
each other to maintain homeostasis.
A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse
should respond with which statement?
1."The work of breathing is increased when the client is anemic."
2."Blood flows more slowly when the hemoglobin or hematocrit is low."
3."The body has to work harder to fight infection in the presence of anemia."
4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."
4.
Oxygen is required to meet the metabolic needs of the body. With decreased hemoglobin, such as in
iron deficiency anemia, the oxygen-carrying capacity of the blood is less than normal. The client feels the
effects of this change as fatigue. Options 1, 2, and 3 are incorrect.
Priority Concepts: Gas Exchange, Perfusion
Which laboratory test results may be associated with peaked or tall, tented T waves on a client's
electrocardiogram (ECG)?
1.Chloride level of 98 mEq/L
2.Sodium level of 135 mEq/L
3.Potassium level of 6.8 mEq/L
4.Magnesium level of 1.6 mEq/L
3.
Hyperkalemia can cause tall, peaked or tented T waves on the ECG. Levels of potassium 5.0 mEq/L or
greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels.
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance.
Which change in vital signs during activity would be the best indicator that the client is tolerating mild
exercise?
1.Oxygen saturation decreased from 96% to 91%.
2.Pulse rate increased from 80 to 104 beats per minute.
3.Blood pressure decreased from 140/86 to 112/72 mm Hg.
4.Respiratory rate increased from 16 to 19 breaths per minute.
4.
Vital signs that remain near baseline indicate good cardiac reserve with exercise. Only the respiratory
rate remains within the normal range. Additionally, it reflects a minimal increase. A pulse rate increase
to a rate over 100 beats per minute during mild exercise does not show tolerance, nor does a 5%
decrease in oxygen saturation levels. In addition, blood pressure decreasing by more than 10 mm Hg is
not a sign indicating tolerance of activity.
Priority Concepts: Mobility, Perfusion
A client is being discharged from the hospital after being treated for infective endocarditis. The nurse
should provide the client with which discharge instruction?
1.Take antibiotics until the chest pain is fully resolved.
2.Take acetaminophen (Tylenol) if the chest pain worsens.
3.Use a firm-bristle toothbrush and floss vigorously to prevent cavities.
4.Notify all health care providers (HCP) of the history of infective endocarditis before any invasive
procedures.
4.
The client should alert any HCP about the history of infective endocarditis before any procedure that
involves instrumentation. The HCP should place the client on prophylactic antibiotics if an invasive
procedure is needed. Antibiotics should be taken for the full course of therapy. The client should notify
the HCP if chest pain worsens or if dyspnea or other symptoms occur. The client should use a soft
toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for
bacterial infection.
Priority Concepts: Client Education, Infection
The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery
client. Which action should the nurse include within the plan of care for this client?
1.Use the knee-gatch on the bed.
2.Cover the legs lightly when sitting in a chair.
3.Encourage the client to cross legs when sitting in a chair.
4.Provide pillows for the client to place under the knees as desired.
2.
Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels.
The nurse plans postoperative measures to prevent venous stasis. These include applying elastic
stockings or leg wraps, use of pneumatic compression boots, and discouraging leg-crossing. Clients
should be encouraged to perform passive and active range of motion exercises. The knee gatch on the
bed and pillows under the knees should be avoided because it places pressure on the blood vessels in
the popliteal area, impeding venous return.
The nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks
after hospital discharge. The nurse should include which item in the instructions?
1.Driving is permitted so long as the lap and shoulder seat belts are worn.
2.Lifting should be restricted to objects that do not weigh more than 25 pounds.
3.Use the arms for balance, not weight support, when getting out of bed or a chair.
4.Activities that involve straining may be resumed so long as they do not cause pain.
3.
The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining
on the sternum. Typical discharge activity instructions for the first 6 weeks include instructing the client
to lift nothing heavier than 5 pounds, to not drive, and to avoid any activities that cause straining. These
limitations are to allow for sternal healing, which takes approximately 6 weeks.
The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The P waves and QRS
complexes are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The
overall heart rate is 82 beats/min. The nurse interprets the cardiac rhythm to be which rhythm?
1.Sinus bradycardia
2.Sick sinus syndrome
4.First-degree heart block
3.
Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR
and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second,
respectively.
A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/min. The PR
interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular.
How should the nurse interpret this rhythm?
1.Sinus tachycardia
2.Sinus dysrhythmia
3.Sinus bradycardia
2.
Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an
irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the
sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or
QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets
that the client is experiencing which rhythm?
1.Sinus tachycardia
2.Ventricular fibrillation
3.Ventricular tachycardia
4.Premature ventricular contractions (PVCs)
2.
Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is
instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring
screen. Sinus tachycardia has a recognizable P wave and QRS. Ventricular tachycardia is a regular pattern
of wide QRS complexes. PVCs appear as irregular beats within a rhythm. Each of the incorrect options
has a recognizable complex that appears on the monitoring screen.

A client with myocardial infarction is experiencing new, multiform premature ventricular contractions
(PVCs). Knowing that the client is allergic to lidocaine hydrochloride, the nurse plans to have which
medication available for immediate use?
1.Procainamide
2.Digoxin (Lanoxin)
3.Verapamil (Calan SR)
4.Metoprolol (Lopressor)
1.
Procainamide is an antidysrhythmic that may be used to treat ventricular dysrhythmias in clients who
are allergic to lidocaine. Digoxin is a cardiac glycoside; verapamil is a calcium-channel blocking agent;
metoprolol is a β-adrenergic blocking agent.
A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions
(PVCs). The nurse evaluates this therapy as most effective if the client's PVCs continued to exhibit which
finding?
1.Occur in pairs
2.Appear to be multifocal
3.Fall on the second half of the T wave
4.Decrease to a frequency of less than 6 per minute
4.
PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or
couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client's cardiac
rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are
potentially deadly dysrhythmias.

The nurse is assessing the client's condition after cardioversion. Which observation should be of highest
priority to the nurse?
1.Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2.
Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen

administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway,
however, is always the highest priority.
The home health nurse makes a home visit to a client who has an implantable cardioverter-defibrillator
(ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which
client statement indicates that further teaching is necessary?
1."If I feel an internal defibrillator shock, I should sit down."
2."I won't be able to have a magnetic resonance imaging test (MRI)."
3."My wife knows how to call the emergency medical services (EMS) if I need it."
4."I can stop taking my antidysrhythmic medicine now because I have a pacemaker."
4.
Clients with an ICD usually continue to receive antidysrhythmic medications after discharge from the
hospital. The nurse should stress the importance of continuing to take these medications as prescribed.
The nurse should provide clear instructions about the purposes of the medications, dosage schedule,
and side effects or adverse effects to report. Clients should sit down if they feel an internal defibrillator
shock. They cannot have an MRI because of the possible magnetic properties of the device. Also,
knowledge of how to reach EMS is important.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The
nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the
presence of pacemaker spikes at what point?
1.Before each P wave
2.Just after each P wave
3.Just after each T wave
4.Before each QRS complex
4.
If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS
complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted. A demand
pacemaker fires only when needed and should therefore discharge only when no electrical activity is
occurring in the client's own heart.
A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess
the client for which finding?
1.Bilateral edema
2.Increased calf circumference
3.Diminished distal peripheral pulses
4.Coolness and pallor of the affected limb
2.
The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of
the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema
distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses
are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis
develops silently; that is, the client does not present with any signs and symptoms unless pulmonary
embolism occurs as a complication.
The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions
would the nurse plan, based on the health care provider's prescriptions? Select all that apply.
1.Elevation of the right leg
2.Ambulation in the hall every 4 hours
3.Application of moist heat to the right leg
4.Administration of acetaminophen (Tylenol)
5.Monitoring for signs of pulmonary embolism
1,3,4,5.
Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days
or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed;
anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated
because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the
lungs as a pulmonary embolism.
Priority Concepts: Clotting, Perfusion
A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying
measures to help the client cope with lifestyle changes needed to control the disease process. The nurse
plans to refer the client to which member of the health care team?
1.Dietitian
2.Medical social worker
3.Pain management clinic
4.Smoking-cessation program
4.
Buerger's disease is a vascular occlusive disease that affects the medium and small arteries and veins.
Smoking is highly detrimental to the client with Buerger's disease, so stopping smoking completely is
recommended. Because smoking is a form of chemical dependency, referral to a smoking-cessation
program may be helpful for many clients. For many clients with Buerger's disease, symptoms are
relieved or alleviated once smoking stops. A dietitian, a medical social worker, and a pain management
clinic are not specifically associated with the lifestyle changes required in this disorder although they
may be needed if secondary problems arise.
Priority Concepts: Care Coordination, Perfusion
The home health nurse is visiting a client who has had a prosthetic valve replacement for severe mitral
valve stenosis. Which statement by the client reflects an understanding of specific postoperative care
after this surgery?
1."I need to count my pulse every day."
2."I have to do deep breathing exercises every 2 hours."
3."I threw away my straight razor and bought an electric razor."
4."I have to go to the bathroom frequently because of my medication."
3.
Prosthetic valves require long-term anticoagulation to prevent clots from forming on the "foreign" tissue
implanted in the client's body. Anticoagulation therapy requires clients to avoid any trauma or potential
means of causing bleeding, such as the use of straight razors. Counting pulse, deep breathing exercises,
and going to the bathroom frequently are not specifically related to postoperative care after prosthetic
valve replacement.
Priority Concepts: Client Education, Clotting
The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease
progression. Which items should the nurse include on a list of suggestions for the client? Select all that
apply.
1.Soak the feet in hot water daily.
2.Be careful not to injure the legs or feet.
3.Use a heating pad on the legs to aid vasodilation.
4.Walk each day to increase circulation to the legs.
5.Cut down on the amount of fats consumed in the diet.
2,4,5.
Long-term management of peripheral arterial disease consists of measures that increase peripheral
circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot
care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity is
contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the
affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and
nutritional requirements of the tissue even further.
Priority Concepts: Perfusion, Tissue Integrity
The home health nurse visits a client recovering from cardiogenic shock secondary to an anterior
myocardial infarction and provides home care instructions to the client. Which statement by the client
indicates an understanding of these home care measures?
1."I exercise every day after breakfast."
2."I've gained 8 pounds since discharge."
3."I take an antacid when I experience epigastric pain."
4."I have planned periods of rest at 10:00 am and 3:00 pm daily."
4.
The client recovering from cardiogenic shock secondary to a myocardial infarction will require a
progressive rehabilitation related to physical activity. The heart requires several months to heal from an
uncomplicated myocardial infarction. The complication of cardiogenic shock increases the recovery
period for healing. Paced activities with planned rest periods will decrease the chance of experiencing
angina or delayed healing. It is best to allow the meal to settle prior to activity in order to improve
circulation to the heart during exercise. Epigastric pain or a weight gain of 8 pounds is significant and
should be reported to the health care provider, at which point follow-up should occur.

A client who had coronary artery bypass surgery states to the home health nurse: "get so frustrated. I
can't even do my gardening." The nurse then assesses the client for activity level since the surgery.
Which client statement indicates a need for further teaching?
1."I pace my activities throughout the day."
2."I plan regular rest periods during the day."
3."I avoid outdoor physical activity during the heat of the day."
4."I try to walk immediately after lunch, after I've finished my morning housecleaning."
4.
Exercise is an integral part of the rehabilitation program. It is necessary for optimal physiological
functioning and psychological well-being. Postoperative physical rehabilitation must be progressive with
planned periods of rest. Exercise tolerance is judged by the client's response, such as heart rate and
endurance. Planning regular rest periods, pacing activities, and avoiding outdoor activities during the
heat of the day are appropriate client activities. The correct option lacks planned periods of rest, and the
client has grouped too many activities in a brief period of time, which will decrease endurance. Also,
exercise after meals can decrease the client's tolerance because of shunting of blood to the
gastrointestinal tract for digestion.
Strategy(s): Strategic Words, Negative Event Query, Comparable or Alike Options
The nurse notes that a client's cardiac rhythm shows absent P waves and no PR interval. How should the
nurse interpret this rhythm?
1.Bradycardia
2.Tachycardia
4.Normal sinus rhythm (NSR)
3.
In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is
normal and constant. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR a P
wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20
seconds in duration, and the QRS interval is 0.06 to 0.10 seconds in duration.
A nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild
pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and
document this finding?
1.1+ edema
2.2+ edema
3.3+ edema
4.4+ edema
1.
Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for
edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia.
Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is
present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no
perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting,
indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long
time, and leg is very swollen.
Integrated Process: Communication and Documentation
The postmyocardial infarction client is scheduled for a technetium 99m ventriculography (multigated
acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure?
1.A Foley catheter
2.Signed informed consent
3.A central venous pressure (CVP) line

4.Notation of allergies to iodine or shellfish
2.
MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood
flow, and to determine left ventricular function. A radioisotope is injected intravenously; therefore a
signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure
does not use radiopaque dye; therefore allergies to iodine and shellfish are not a concern.
Client Needs: Safe and Effective Care Environment
The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse should
address with the client which most important measure to ensure client safety?
1.Assessing pain
2.Administering vasodilators
3.Avoiding over-the-counter medications
4.Moving slowly from a sitting to a standing position
4.
Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return
obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not
prescribed for the client with cardiomyopathy. Options 1 and 3, although important, are not directly
related to the issue of safety.
Client Needs: Safe and Effective Care Environment
Priority Concepts: Client Education, Safety
A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus
tachycardia. Which nursing action should be included in the client's plan of care?
1.Limiting oral and intravenous fluids
2.Measuring the client's pulse each shift

3.Providing the client with short, frequent walks
4.Eliminating sources of caffeine from meal trays
4.
Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia,
certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate
tachycardia. Option 2 will not decrease the heart rate. Additionally, the pulse should be taken more
frequently than each shift.
The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the
defibrillator to which starting energy range level, depending on the specific health care provider (HCP)
prescription?
1.50 to 100 joules
2.150 to 300 joules
3.300 to 350 joules
4.350 to 400 joules
1.
For cardioversion procedures, the defibrillator is charged to the energy level prescribed by the HCP.
Countershock usually is started at 50 to 100 joules. Options 2, 3, and 4 are incorrect.
A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What
manifestation should the nurse observe for when performing the client's focused assessment?
1.Flat neck veins
2.Nausea and vomiting

3.Hypotension and dizziness
4.Clubbed fingertips and headache
3.
The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk
for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain
or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and
distended neck veins.
The nurse has provided self-care activity instructions to a client after insertion of an automatic internal
cardioverter-defibrillator (AICD). The nurse determines that further instruction is needed if the client
makes which statement?
1."I can perform activities such as swimming, driving, or operating heavy equipment as I need to."
2."I need to avoid doing anything that could involve rough contact with the AICD insertion site."
3."I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate
cutoff on the AICD."
4."I should keep away from electromagnetic sources such as transformers, large electrical generators,
metal detectors, and I shouldn't lean over running motors."
1.
Post discharge instructions typically include avoiding tight clothing or belts over AICD insertion sites;
rough contact with the AICD insertion site; and electromagnetic fields such as with electrical
transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients
also must alert health care providers (HCP) or dentists to the presence of the device because certain
procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided
to prevent device malfunction. Clients should follow the specific advice of a HCP regarding activities that
are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment.
Priority Concepts: Client Education, Safety

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse
determines that the client understands the effect of this medication on the diet if the client states to
avoid which fruit?
1.Apples
2.Pears
3.Bananas
4.Cranberries
3.
Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits
that are naturally higher in potassium include avocados, bananas, fresh oranges, mangos, nectarines,
papayas, and prunes.
Priority Concepts: Client Education, Nutrition
A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for
which manifestation that differentiates pericarditis from other cardiopulmonary problems?
1.Anterior chest pain
2.Pericardial friction rub
3.Weakness and irritability
4.Chest pain that worsens on inspiration
2.
A pericardial friction rub is heard when inflammation of the pericardial sac is present during the
inflammatory phase of pericarditis. Anterior chest pain may be experienced with angina pectoris and
myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a wide
variety of disorders. Chest pain that worsens on inspiration is characteristic of both pericarditis and
pleurisy.

Priority Concepts: Clinical Judgment, Inflammation
Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions
(PVCs). Which heart rhythm will the nurse most anticipate in this client if PVCs are occurring?
1.A P wave preceding every QRS complex
2.QRS complexes that are short and narrow
3.Inverted P waves before the QRS complexes
4.Premature beats followed by a compensatory pause
4.
PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P
waves, presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.
The nurse is developing a plan of care for a client with pulmonary edema. The nurse establishes a goal to
have the client participate in activities that reduce cardiac workload. The nurse should identify which
client action as contributing to this goal?
1.Using a bedside commode
2.Sleeping in the supine position
3.Elevating the legs when in bed
4.Using seasonings to improve the taste of food
1.
Using a bedside commode decreases the work of getting to the bathroom or struggling to use the
bedpan. The supine position increases respiratory effort and decreases oxygenation. Elevating the
client's legs increases venous return to the heart, increasing cardiac workload. This increases cardiac
workload. Seasonings may be high in sodium.

Priority Concepts: Functional Ability, Perfusion
The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How
should the nurse assess for this disease?
1.Checking for a rash on the digits
2.Observing for softening of the nails or nail beds
3.Palpating for a rapid or irregular peripheral pulse
4.Palpating for diminished or absent peripheral pulses
4.
Raynaud's disease produces closure of the small arteries in the distal extremities in response to cold,
vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for
interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed
healing of cuts or injuries. The nails grow slowly, become brittle or deformed, and heal poorly around
the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse
would not be noted.
Strategy(s): ABCs—Airway, Breathing, Circulation
The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after
surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that
apply.
1.Place in Fowler's position for eating.
2.Encourage coughing with deep breathing.
3.Encourage increased oral intake of water daily.
4.Place thigh-length elastic stockings on the client.
5.Place sequential compression boots on the client.
6.Encourage the intake of dark green, leafy vegetables.
2,3,4.
The client with DVT may require bedrest to prevent embolization of the thrombus resulting from
skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus
autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce
peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents
complications of immobility by encouraging coughing and deep breathing. Venous return is important to
maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower
extremities by avoiding hip flexion, which occurs with Fowler's position. The nurse avoids providing
foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with
anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not
include use of sequential compression boots for an existing thrombus. They are used only to prevent
DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to
pulmonary embolism.
Priority Concepts: Clotting, Safety
Spironolactone (Aldactone) is prescribed for a client with heart failure. In providing dietary instructions
to the client, the nurse identifies the need to avoid foods that are high in which electrolyte?
1.Calcium
2.Potassium
3.Magnesium
4.Phosphorus
2.
Spironolactone (Aldactone) is a potassium-retaining diuretic, and the client should avoid foods high in
potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client
does not need to avoid foods that contain calcium, magnesium, or phosphorus while taking this
medication.
Priority Concepts: Client Education, Fluid and Electrolyte Balance
A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The
nurse should suspect myocardial injury or infarction if which laboratory value came back elevated?
1.Myoglobin
2.Cardiac troponin
3.C-reactive protein
4.Creatine kinase (CK)
2.
Cardiac troponin elevations indicate myocardial injury or infarction. Although the remaining options may
also rise, they are not definitive enough to draw a conclusive diagnosis.
The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping.
The nurse evaluates that the client understands activity and positioning limitations if the client states
that which action is appropriate to do?
1.Walk for as long as possible each day.
2.Cross the legs at the ankle only, not at the knee.
3.Lie down with the legs elevated and avoid sitting.
4.Sit in a chair 3 times a day for 3 hours at a time.
3.
The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods.
The client should remain lying down unless performing a specific activity for the first few days after the
procedure. Prolonged standing or sitting increases the risk of edema in the legs by decreasing blood
return to the heart. The client should avoid crossing the legs at any level for the same reason.
A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms.
The client suddenly complains of chest pain. Which question should best help a nurse discriminate pain
caused by a noncardiac problem?
1."Can you describe the pain to me?"

2."Have you ever had this pain before?"
3."Does the pain get worse when you breathe in?"
4."Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"
3.
Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location,
intensity, duration, precipitating and alleviating factors, and associated symptoms). The remaining
options may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually
worsens on inspiration.
A client with myocardial infarction has been transferred from a coronary care unit to a general medical
unit with cardiac monitoring via telemetry. The nurse should plan to allow for which client activity?
1.Strict bed rest for 24 hours after transfer
2.Bathroom privileges and self-care activities
3.Ad lib activities because the client is monitored
4.Unsupervised hallway ambulation with distances under 200 feet
2.
On transfer from the coronary care unit, the client is allowed self-care activities and bathroom
privileges. Strict bedrest is unnecessary and can be harmful and promote emboli. Supervised ambulation
in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).
Priority Concepts: Mobility, Perfusion
A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which
conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply.
1.Emotional stress
3.Nutritional anemia
4.Peptic ulcer disease
5.Recent upper respiratory infection
1,2,3,5.
Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections,

anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism),
pulmonary disease, and hypervolemia.
The nurse should recognize that a client who has developed severe pulmonary edema would most likely
exhibit which symptom?
1.Mild anxiety
2.Slight anxiety
3.Extreme anxiety
4.Moderate anxiety
3.
Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a
sense of drowning, suffocation, or smothering. Therefore the client will experience extreme anxiety.
Client Needs: Psychosocial Integrity
Priority Concepts: Anxiety, Gas Exchange
A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for
additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also
be started on digoxin (Lanoxin), which laboratory result should the nurse review as the priority?
1.Sodium level
2.Digoxin level
3.Creatinine level
4.Potassium level
4.
The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened
digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also
predisposes the client to ventricular dysrhythmias.
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
A nurse is caring for a client with unstable ventricular tachycardia. The nurse should instruct the client to
take which action, if prescribed, during an episode of ventricular tachycardia?
1.Lie down flat in bed.
2.Remove any metal jewelry.
3.Breathe deeply, regularly, and easily.
4.Inhale deeply and cough forcefully every 1 to 3 seconds.
4.
Restorative coughing techniques are sometimes used in the client with unstable ventricular tachycardia.
The nurse tells the client to use cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling
deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or
sustain the cerebral and coronary circulation for a short time until other measures can be implemented.
The other options will not assist in terminating the dysrhythmia.

A nurse employed in a cardiac unit determines that which client is the least likely to have implantation
of an automatic internal cardioverter-defibrillator (AICD)?
1.A client with syncopal episodes related to ventricular tachycardia
2.A client with ventricular dysrhythmias despite medication therapy
3.A client with an episode of cardiac arrest related to myocardial infarction
4.A client with three episodes of cardiac arrest unrelated to myocardial infarction
3.
An AICD detects and delivers an electrical shock to terminate life-threatening episodes of ventricular
tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high
risk, including those who have syncopal episodes related to ventricular tachycardia, those who are
refractive to medication therapy, and those who have survived sudden cardiac death unrelated to
myocardial infarction.
A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right
subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter?
1.Limiting both movement and abduction of the left arm
2.Limiting both movement and abduction of the right arm
3.Assisting the client to get out of bed and ambulate with a walker
4.Having the physical therapist do active range-of-motion exercises to the right arm
2.
In the first several hours after insertion of a permanent or temporary pacemaker, the most common
complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the
client's activities of the arm on the side of the insertion site. Therefore, options 1, 3, and 4 are incorrect.
Priority Concepts: Mobility, Safety

………………………………………………………………………………………………………………………………………………………………
The nurse instructs a patient about modifiable risk factors for coronary artery disease. Which statements
indicate that teaching has been effective? (Select all that apply)
1. I should stop smoking to reduce my risk of heart disease

2. Restricting my activity reduces the onset of heart disease
3. I should drink alcohol because this prevents hearts disease
4. There is not much that can be done to prevent heart disease
5. Obesity is a risk actor that I can change to reduce the onset of heart disease
1, 5
Modifiable risk factors for the development of coronary artery disease include obesity, smoking, and
physical inactivity
A patient is prescribed lovastatin (Mevacor) for hyperlipidemia. What should the nurse instruct the
patient about this medication?
1. Abstain from alcohol use while taking this drug

2. Take the drug with meals to minimize gastric distress
3. Promptly report muscle pain or tenderness to the physician
4. Consume a diet that includes no more than 20% of calories from saturated fat.
3. Lovastatin is a first line drug for treating hyperlipidemia and can cause myopathy. All patients should
be instructed to report muscle pain and weakness or brown urine, which is an indication of muscle
breakdown.
The nurse is caring for a patient with stable angina. Which assessment finding would be consistent with
this medical diagnosis?
1. Persistent ECG changes

2. Increasing nocturnal pain
3. Correlation between activity level and pain
4. Evidence of impaired cardiac output such as weak peripheral pulses.
3. Stable angina is the most common and predictable form of angina. It occurs with a predictable
amount of activity or stress and usually occurs when the work of the heart is increased by physical
exertion, exposure to the cold, or by stress.
The nurse is caring for a patient with acute coronary syndrome. Which nursing diagnosis should be the
priority for this patient?
1. Anxiety related to unknown outcome of disorder

2. Decreased cardiac output related to myocardial ischemia
3. Ineffective Health Maintenance related to lack of knowledge about coronary heart disease
4. Ineffective tissue perfusion: cardiopulmonary related to underlying coronary heart disease
4. Acute coronary syndrome is a dynamic state in ehich coronary blood flow is acutely reduced, but not
fully occluded. Myocardial cells are injured by acute ischemia that redults. The most important goal of
care is to reestablish tissue perfusion through the use of medication or surgery.
The nurse is caring for a patient recovering from a coronary angioplasty with stent placement. Which
intervention is a priority for the patient at this time?
1. Securing chest tubes to bedding
2. Maintaining leg extension on the affected side
3. Discontinuing intravenous lines when taking oral fluids
4. Treating chest pain with intravenous morphine as needed
2. The cardiac catheter used to insert the stent is usually inserted via the femoral artery, a large, high-
pressure vessel. The leg is maintained in extension for a prescribed period after the procedure to reduce
the risk of bleeding, hematoma formation, or clot formation at the insertion site.
The nurse is planning care for a patient with acute myocardial infarction. What goals should the nurse
use to guide this patient's care? (Select all that apply)
1. Relieve chest pain

2. Prevent complications
3. Reduce blood viscosity
4. Decrease cardiac workload
5. Reduce myocardial damage
1,2,4,5
Immediate treatment goals for the patient with an acute myocardial infarction are to reduce chest pain,
myocardial damage, decrease cardiac workload, and prevent complication. Blood viscosity is not
implicated in the development of an acute MI, but plays a role in peripheral vascular resistance.
The nurse is determining nursing diagnoses appropriate for a patient scheduled for fibrinolytic therapy.
Which nursing diagnosis would a priority for this patient?
1. Anxiety
2. Ineffective protection
3. Risk for powerlessness
4. Ineffective health maintenance
2. Fibrinolytic therapy, administered to restore myocardial perfusion, disruts the clotting cascade and
can lead to potentially serious bleeding. Establishing bleeding precautions is vital to preserve physiologic
integrity. The diagnosis Ineffective protection would be the priority for this patient.
The nurse is reviewing laboratory results for a patient admitted with acute chest pain. Which laboratory
value should cause the nurse the most concern?
1. AST 65 units/L
2. CK 320 units/L
3. Hematocrit 35%
4. APTT 35 seconds
2. Creatine kinase is an important enzyme for celar function found principally in cardiac and skeletal
muscle and the brain. CK levels rise rapidly with damage to these tissues, appearing in the serum 4-6
hours after an acute MI, peaking within 12-14 hours and then declining. The CK level correlates with the
size of the infarction; the greater the amount of infarcted tissue, the higher the serum CK level.
AST is a liver enzyme
The nurse recognizes that a patient has developed second-degree AV block, type II (Mobitz II). Which
action should the nurse take at this time?
1. Record the finding in the chart

2. Places the patient in Fowler's position
3. Prepare for temporary pacemaker insertion
4. Administer a Class IB antidysrhythmic drug
Mobitz type II AV block often is assocaited with a large anterior MI and has a high mortality rate.
Pacemaker therapy may be necessary to maintain effective venticular contractions and CO.
Class IB drugs are used primarily to treat dysrhythmias, including PVCs and ventricular tachycardia.
The nurse identifies that a patient has sinus bradycardia with a heart rate at 45 bpm. What should the
nurse do first?
1. Assess mental status and blood pressure

2. Prepare to administer intravenous atropine
3. Assess peripheral pulses on all four extremities
4. Determine if an apical-radial pulse deficit is present
1. Sinus bradycardia may be well tolerated in some patients and assessment is needed before treating. If
decreased mental status and hypotension are presentIV atropine may be indica

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CARDIOVASCULAR (EXAMAINATION)

Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Planning

Content Area: Adult Health: Cardiovascular

Strategy(s): Comparable or Alike Options

Priority Concepts: Perfusion, Safety

2.Sick sinus syndrome

3.Normal sinus rhythm

4.First-degree heart block

Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Assessment

Content Area: Adult Health: Cardiovascular

2.Call the health care provider.

3.Check the client's status and lead placement.

4.Press the recorder button on the electrocardiogram console.

Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode

Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Implementation

Content Area: Adult Health: Cardiovascular

Strategy(s): Strategic Words, Steps of the Nursing Process

2.Causative factors, such as caffeine

3.Precipitating factors, such as infection

4.Blood pressure and oxygen saturation

Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Assessment

Strategy(s): Strategic Words, ABCs—Airway, Breathing, Circulation

Priority Concepts: Clinical Judgment, Perfusion

3.Oxygen flow rate

Cognitive Ability: Evaluating

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Evaluation

Content Area: Adult Health: Cardiovascular

Strategy(s): Strategic Words, ABCs—Airway, Breathing, Circulation

Priority Concepts: Clinical Judgment, Perfusion

1.Anxiety level of the client and family

2.Presence of a Medic-Alert card for the client to carry

3.Knowledge of restrictions of postdischarge physical activity

Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Assessment

Strategy(s): Strategic Words, Maslow's Hierarchy of Needs Theory

Priority Concepts: Perfusion, Safety

4.Normal sinus rhythm

Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Assessment

Content Area: Adult Health: Cardiovascular

Priority Concepts: Clinical Judgment, Perfusion

Cognitive Ability: Analyzing

Integrated Process: Nursing Process: Assessment

Content Area: Adult Health: Cardiovascular

Priority Concepts: Clinical Judgment, Perfusion

1.Rising blood pressure

2.Clearly audible heart sounds

3.Client expressions of relief

4.Rising central venous pressure

Cognitive Ability: Evaluating

Client Needs: Physiological Integrity

Integrated Process: Nursing Process: Evaluation