Check My Twitter Account @nursetopia or IG @nursetopia1 For More Nursing Test Banks, Sample Exam, Reviewers, and Notes

Check my twitter account @nursetopia or IG @nursetopia1
for more nursing test banks, sample exam, reviewers, and notes.
Question 1
Type: MCSA
The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The
student nurse asks how the S1 heart sound is produced. Which of the following is the nurse’s best
response?
1. “It results from the closure of the semilunar valves.”
2. “It is heard when the aortic valve closes just slightly faster than the pulmonic valve.”
3. “It results from the closure of the atrioventricular valves.”
4. “It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.”
Correct Answer: 3
Rationale 1: The S2 sounds results from the closure of the semilunar valves. The semilunar valves
include the aortic and pulmonic valves.
Rationale 2: A splitting of the S2 occurs toward the end of inspiration in some individuals.
This results from a slight difference between the time the aortic and pulmonic valves close.
Rationale 3: The S1 heart sound results from closure of the atrioventricular (AV) valves.
Rationale 4: The S4 sound may be heard in children, well-conditioned athletes, and healthy
elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood
into the ventricles in late diastole.
Global Rationale: The S2 sounds results from the closure of the semilunar valves. The semilunar
valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of
inspiration in some individuals. This results from a slight difference between the time the aortic and
pulmonic valves close. The S1 heart sound results from closure of the atrioventricular (AV) valves.
The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals
without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in
late diastole.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.
Question 2
Type: HOTSPOT
The client’s healthcare provider determines that the client’s left ventricle is functioning adequately.
Identify the left ventricle by drawing an arrow to it.
Standard Text: Select the correct area on the image.
Correct Answer:
Rationale :
Global Rationale:
Cognitive Level: Remembering
Client Need Sub:
Question 3
Type: FIB
The client’s stroke volume is 72 ml/beat. The client’s heart rate is 82 beats per minute.
What is the client’s cardiac output?____________
Standard Text:
Correct Answer: 5904 mL per minute.
Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat.
Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected
from the left ventricle over 1 minute. Normal adult cardiac output is 4 to 8 liters per minute. The
formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate for
1 minute.
72 ml/ beat x 82 beats/ minute= 5904 mL/ minute
Global Rationale:
Client Need Sub:
Question 4
Type: HOTSPOT
The nurse is performing a cardiac assessment and prepares to palpate the client’s heartbeat on
the client’s chest. Draw an arrow pointing to this area.
Correct Answer:
Rationale : The point of maximal impulse or PMI is located at the fifth intercostal space at the
midclavicular line.
Global Rationale:
Cognitive Level: Understanding
Client Need Sub:
Learning Outcome: 17.2: Recognize landmarks that guide assessment of the

cardiovascular system.
Question 5
Type: HOTSPOT
The nurse is reviewing the client’s chart. The client’s blood pressure has been consistently elevated
over the last eight years. The client has been noncompliant with lifestyle changes and medication
use designed to reduce the client’s blood pressure. Today, the nurse is able to palpate a heave on
the client’s chest. Draw an arrow to the most likely location that the nurse is able to palpate the
heave.
Correct Answer:
Rationale : Pulsations or heaves palpated at the right sternal border in the second intercostal
space are associated with systemic hypertension.
Global Rationale:
Cognitive Level: Analyzing
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 17.2: Recognize landmarks that guide assessment of the

Question 6
Type: MCMA
During the focused interview, the client answers the nurse’s questions. Which of the following
statements by the client suggests that the client has an increased risk of developing cardiovascular
disease?
Standard Text: Select all that apply.
1. “I have been stressed out since my divorce last year.”
2. “I’m what you call a Type C personality.”
3. “I went on this new diet because I gained 30 pounds in the last 9 months.”
4. “On my new diet, I can eat only grains and vegetables.”
5. “I think about my job all of the time.”
Correct Answer: 1,3,4,5
Rationale 1: “I have been stressed out since my divorce last year.” Psychosocial problems
and excessive stress can increase the client’s risk for developing cardiovascular disease.
Rationale 2: “I’m what you call a Type C personality.” Type A personalities tend to develop
cardiovascular disease more often than people with other personality types.
Rationale 3: “I went on this new diet because I gained 30 pounds in the last 9
months.” Obesity and a high percentage of body fat are risk factors for cardiovascular disease.
Weight gain may accompany physical problems including systemic diseases such as diabetes,
which increases this client’s risk for developing cardiovascular disease.
Rationale 4: “On my new diet, I can eat only grains and vegetables.” The nurse must note if
the client has been dieting to reduce weight. Many diets deplete valuable electrolytes and subject
the client to potential complications. Muscle wasting may occur if the diet is deficient in protein.
Lack of protein may compromise cardiac function.
Rationale 5: “I think about my job all of the time.” Stress increases the stimulation of the client’s
sympathetic nervous system and can increase the client’s risk for developing cardiovascular
disease.
Global Rationale: Psychosocial problems and excessive stress can increase the stimulation of the
client’s sympathetic nervous system, thereby increasing the client’s risk for developing
cardiovascular disease. Type A personalities tend to develop cardiovascular disease more often
than people with other personality types. Obesity and a high percentage of body fat are risk factors
for cardiovascular disease. Weight gain may accompany physical problems including systemic
diseases such as diabetes, which increases this client’s risk for developing cardiovascular disease.
The nurse must note if the client has been dieting to reduce weight. Many diets deplete valuable
electrolytes and subject the client to potential complications. Muscle wasting may occur if the diet is
deficient in protein. Lack of protein may compromise cardiac function.
Client Need Sub:
Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.
Question 7
Type: MCSA
During the focused interview, the client makes the following statements. Which of the following
statements indicates that the client has an increased risk of developing cardiovascular disease?
1. “I was diagnosed with hypothyroidism about 5 years ago.”
2. “My doctor always tells me when I come in that my blood pressure is low.”
3. “I know my grandmother had diabetes, but every time it has been checked mine has been
normal.”
4. “My total cholesterol has always been around 170.”
Correct Answer: 1
Rationale 1: Hypothyroidism may increase the client’s risk for developing cardiovascular disease.
Rationale 2: Hypertension, not hypotension, is associated with the development of cardiovascular

disease.
Rationale 3: Normal serum glucose levels indicate that the client does not currently have diabetes
and so this client’s risk is not necessarily increased.
Rationale 4: The client’s total cholesterol level is within normal limits. High cholesterol levels would
increase the client’s risk for developing cardiovascular disease.
Global Rationale: Hypothyroidism may increase the client’s risk for developing cardiovascular disease.
Hypertension, not hypotension, is associated with the development of cardiovascular disease. Normal
serum glucose levels indicate that the client does not currently have diabetes and so this client’s risk is
not necessarily increased. The client’s total cholesterol level is within normal limits. High cholesterol
levels would increase the client’s risk for developing cardiovascular disease.
Client Need Sub:
Question 8
Type: MCSA
The nurse is performing a focused interview with an adult male client who recently experienced a
myocardial infarction. The nurse requests information about how he felt during the time of the
myocardial infarction. Which of the following client statements would be unexpected?
1. “I couldn’t catch my breath.”
2. “My chest didn’t actually ever hurt.”
3. “My wife said I looked like someone poured water all over me.”
4. “I got so sick to my stomach.”
Correct Answer: 2
Rationale 1: Typically males who are experiencing a myocardial infarction will complain of dyspnea.
Rationale 2: Typically males who are experiencing a myocardial infarction will complain of chest
pain that is prolonged, dull, and radiates to the shoulder or jaw. Females are more likely to
experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without actual
chest pain.
Rationale 3: In males, the pain of MI is often accompanied by diaphoresis.
Rationale 4: In males, the pain of MI is often accompanied by nausea.
Global Rationale: Typically males who are experiencing a myocardial infarction will complain of
dyspnea, and chest pain that is prolonged, dull, and radiates to the shoulder or jaw. In males, the
pain is often accompanied by diaphoresis and they may complain of nausea. Females are more
likely to experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without
actual chest pain.
Client Need Sub:
Question 9
Type: MCSA
The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the
client’s coronary arteries. Which of the following questions by the nurse has the highest priority to
help the nurse determine the client’s most important risk factor for this condition?
1. “Can you please tell me about the vitamins or supplements that you take?”
2. “Have you ever been diagnosed with rheumatic fever?”
3. “Do you smoke or are you exposed to secondhand smoke?”
4. “Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or
echocardiogram, or a surgical procedure for a cardiovascular problem?”
Correct Answer: 3
Rationale 1: Information about vitamin and supplement use is important but is not specifically
related to atherosclerosis and coronary artery disease.
Rationale 2: A history of rheumatic fever can increase the client’s risk for valvular problems but does
not necessarily increase the client’s risk for developing atherosclerosis and coronary artery disease.
Rationale 3: The most important question regarding this client’s history and recent diagnosis is
about exposure to cigarettes smoke. The chemical contained in the cigarette smoke injures the inner
wall of arterial vessels and contributes to the subsequent development of a coronary artery plaque.
Rationale 4: Diagnostic testing may help the nurse determine if there was a previous suspicion that
the client had developed a cardiovascular problem, but is not specifically related to coronary artery
disease and atherosclerosis.
Global Rationale: Information about vitamin and supplement use is important but is not specifically
related to atherosclerosis and coronary artery disease. A history of rheumatic fever can increase
the client’s risk for valvular problems but does not necessarily increase the client’s risk for
developing
atherosclerosis and coronary artery disease. The most important question regarding this client’s
history and recent diagnosis is about exposure to cigarettes smoke. The chemical contained in the
cigarette smoke injures the inner wall of arterial vessels and contributes to the subsequent
development of a coronary artery plaque. The question regarding diagnostic testing may help the
nurse determine if there was a previous suspicion that the client had developed a cardiovascular
problem, but is not specifically related to coronary artery disease and atherosclerosis.
Client Need Sub:
Question 10
Type: MCMA
The nurse is preparing to assess the female client’s cardiovascular system during the client’s visit
to the healthcare provider’s office. Which of the following items should the nurse have available in
the room in order to complete the examination?
1. Ruler (metric)
2. Stethoscope
3. Lamp
4. Client gown and a drape
5. Doppler
Correct Answer: 1,2,3,4,5
Rationale 1: Ruler (metric). The nurse will require a metric ruler to determine distention of
blood vessels.
Rationale 2: Stethoscope. The nurse will require a stethoscope to auscultate the client’s heart and
arteries.
Rationale 3: Lamp. The nurse will require a lamp or adequate lighting in the room for the
inspection process of the assessment.
Rationale 4: Client gown and a drape. Female clients should be provided with a gown and a drape
for this examination in order to maintain privacy and avoid overexposure.
Rationale 5: Doppler. A Doppler device can be used to determine the presence of a pulse if the
nurse is unable to adequately palpate the pulse.
Global Rationale: The nurse will require a metric ruler to determine distention of blood vessels. The
nurse will require a stethoscope to auscultate the client’s heart and arteries. The nurse will require a
lamp or adequate lighting in the room for the inspection process of the assessment. Female clients
should be provided with a gown and a drape for this examination in order to maintain privacy and
avoid overexposure. A Doppler device can be used to determine the presence of a pulse if the nurse
is unable to adequately palpate the pulse.
Client Need Sub:
Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular system.
Question 11
Type: MCMA
The nurse is preparing to assess the client’s cardiovascular system. Which of the following
positions will the nurse need to place the client in during the assessment?
1. Dorsal recumbent
2. Leaning forward
3. Right lateral position
4. Left lateral position
5. Sitting upright
Rationale 1: Dorsal recumbent. The client will be asked to remain in a supine position or dorsal
recumbent position for part of the examination. The nurse may be able to auscultate murmurs better
while the client is in this position.
Rationale 2: Leaning forward. The client will be asked to lean forward during auscultation of the
heart. The nurse should listen to the client’s heart while the client is leaning forward.
Rationale 3: Right lateral position. This is not a common position to place the client in during
this type of examination.
Rationale 4: Left lateral position. The client will be asked to lie on the left side during part of this
examination. In obese clients, heart sounds are best heard at the apical area with the client in the
left lateral position.
Rationale 5: Sitting upright. The nurse will most likely begin this examination while the client is in
this position. This is the position the nurse should ask the client to assume when beginning chest
auscultation.
Global Rationale: The nurse will most likely begin this examination with the client sitting upright.
This is the position the nurse should ask the client to assume when beginning chest auscultation.
The client will be asked to remain in a supine position or dorsal recumbent position for part of the
examination. The nurse may be able to auscultate murmurs better while the client is in this position.
The client will be asked to lean forward during auscultation of the heart. The nurse should listen to
the client’s heart while the client is leaning forward. The client will be asked to lie on the left side
during part of this examination. In obese clients, heart sounds are best heard at the apical area with
the client in the left lateral position. Right lateral position is not a common position to place the client
in during this type of examination.
Client Need Sub:
Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular system.
Question 12
Type: SEQ
The nurse is preparing to perform a cardiac assessment on a client. Rank the following pieces of
the assessment in order of occurrence.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Auscultation of the client’s heart, apical pulse, and carotid arteries
Choice 2. Inspection of the client’s head and neck, chest, abdomen, and extremities
Choice 3. Percussion of the client’s chest
Choice 4. Palpation of the precordium and pulses
Rationale 1: The fourth of these steps is auscultation. Auscultation includes the heart in five areas
with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are
auscultated.
Rationale 2: The first of these steps is inspection of the client’s head and neck. The upper
extremities, chest, abdomen, and lower extremities are also inspected.
Rationale 3: The third of these steps is percussion, which is conducted to determine the cardiac
borders.
Rationale 4: The second of these steps is palpation. Palpation includes the precordium and
carotid pulses.
Global Rationale: Physical assessment of the cardiovascular system follows an organized pattern.
It begins with inspection of the client’s head and neck. The upper extremities, chest, abdomen, and
lower extremities are also inspected. Palpation includes the precordium and carotid pulses.
Percussion of the chest is conducted to determine the cardiac borders. Auscultation includes the
heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and
the apical pulse are auscultated.
Client Need Sub:
Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular
system.
Question 13
Type: MCMA
The student nurse is assessing the client’s cardiovascular system while the experienced nurse
observes. The employment of which of the following techniques by the student nurse indicate the
need for further education?
1. The client complains of discomfort while lying flat. The student nurse auscultates the client’s chest
quickly while the client continues to lie flat.
2. The student nurse determines that the apical impulse is located at the fifth intercostal space at the
midclavicular line.
3. The student nurse examines the client’s legs and notes that the client’s hair is evenly distributed.
4. The student nurse gently palpates the client’s carotid arteries simultaneously to determine pulse
strength, rhythm, and rate.
5. The student nurse examines the client’s hands and fingers and notes the presence of clubbing.
Correct Answer: 1,4
Rationale 1: The client complains of discomfort while lying flat. The student nurse
auscultates the client’s chest quickly while the client continues to lie flat. If the client
complains of any discomfort during the examination, the nurse should pause the examination and
the client should be assisted into a more comfortable position for the rest of the examination. Not all
clients will be able to assume every position associated with this examination.
Rationale 2: The student nurse determines that the apical impulse is located at the fifth
intercostal space at the midclavicular line. This is normally where the point of maximal
impulse can be palpated.
Rationale 3: The student nurse examines the client’s legs and notes that the client’s hair is
evenly distributed. This is an appropriate part of the examination. Patchy hair distribution can
indicate that there is a circulatory problem.
Rationale 4: The student nurse gently palpates the client’s carotid arteries simultaneously
to determine pulse strength, rhythm, and rate. The carotid pulses must never be palpated
simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or
asystole.
Rationale 5: The student nurse examines the client’s hands and fingers and notes the
presence of clubbing. It is appropriate to examine the client’s hands and fingers to determine the
existence of peripheral circulatory problems.
Global Rationale: If the client complains of any discomfort during the examination, the nurse should
pause the examination and the client should be assisted into a more comfortable position for the rest
of the examination. Not all clients will be able to assume every position associated with this
examination. If the student nurse has determined the apical impulse to be located at the fifth
intercostal space at the midclavicular line, this is normal. Examining the client’s legs and noting that
the client’s hair is evenly distributed is an appropriate part of the examination. Patchy hair
distribution can indicate that there is a circulatory problem. The carotid pulses must never be
palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe
bradycardia or asystole. It is appropriate to examine the client’s hands and fingers to determine the
existence of peripheral circulatory problems.
Client Need Sub:
Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular
system.
Question 14
Type: HOTSPOT
The client has a history of rheumatic fever. Draw an arrow pointing to the layer of the heart that is
most at risk for damage due to this infection.
Correct Answer:
Rationale : Strep infections can cause rheumatic fever. Rheumatic fever can damage the
client’s endocardium. The endocardium makes up the innermost layer of the heart and valve
tissue.
Global Rationale:
Client Need Sub:
Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.
Question 15
Type: MCSA
The nurse is percussing the client’s anterior chest and notes a dull sound over an area where lung
tissue is normally found. Which of the following would the nurse associate with this finding?
1. This is a normal finding.
2. The client’s heart may be enlarged.
3. The client has developed a murmur.
4. The client has a pulse deficit.
Correct Answer: 2
Rationale 1: This is not a normal finding. When the nurse percusses over lung tissue, the sound
should be described as resonant.
Rationale 2: An enlarged heart emits a dull sound on percussion over a larger area than a heart of
normal size.
Rationale 3: Murmurs can be determined during auscultation of the heart.
Rationale 4: A pulse deficit is present when the apical pulse is greater than the carotid pulse.
Global Rationale: This is not a normal finding. When the nurse percusses over lung tissue, the
sound should be described as resonant. An enlarged heart emits a dull sound on percussion over a
larger area than a heart of normal size. Murmurs can be determined during auscultation of the
heart. A pulse deficit is present when the apical pulse is greater than the carotid pulse.
Client Need Sub:

Question 16
Type: MCSA
The nurse is performing a cardiac assessment on a 70-year-old client admitted with

hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in
diameter at the point of maximal impulse. The nurse suspects that the client may have developed
which of the following problems?
1. Left ventricular hypertrophy
2. Aortic stenosis
3. Right ventricular volume overload
4. Enlarged left atrium
Correct Answer: 1
Rationale 1: If the apical impulse can be palpated in an area greater than 1 cm in diameter or is
laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe
left ventricular volume overload, or severe aortic regurgitation.
Rationale 2: Clients with aortic stenosis often have heaves present at the right sternal border,
second intercostal space.
Rationale 3: The presence of heaves or thrills in the subxiphoid area suggests the presence of right
ventricular volume overload.
Rationale 4: Pulsations or heaves in the left sternal border, second intercostal space,
are associated with an enlarged left atrium.
Global Rationale: If the apical impulse can be palpated in an area greater than 1 cm in diameter or
is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe
left ventricular volume overload, or severe aortic regurgitation. Clients with aortic stenosis often
have heaves present at the right sternal border, second intercostal space. The presence of heaves
or thrills in the subxiphoid area suggests the presence of right ventricular volume overload.
Pulsations or heaves in the left sternal border, second intercostal space, are associated with an
enlarged left atrium.
Client Need Sub:

Question 17
Type: MCSA
A 39-year-old client has been admitted to the hospital with complaints of increasing fatigue. The
history is remarkable for rheumatic fever as a child. The nurse hears a diastolic murmur at the apex
when the client is in the left lateral position. The murmur is described as a rumble without radiation.
This description is most consistent with:
1. tricuspid regurgitation.
2. mitral regurgitation.
3. mitral stenosis.
4. pulmonic stenosis.
Correct Answer: 3
Rationale 1: The murmur associated with tricuspid regurgitation is often described as systolic,
blowing, high-pitched, and may radiate.
Rationale 2: Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to
the left axilla.
Rationale 3: The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at
the apex while the client is placed in the left lateral position. It is a low-frequency diastolic murmur, which
does not radiate. It is often caused by rheumatic fever or a cardiac infection.
Rationale 4: The murmur associated with pulmonic stenosis is often described as a harsh, systolic
murmur heard best over the pulmonic area with radiation to the neck.
Global Rationale: The murmur associated with tricuspid regurgitation is often described as systolic,
blowing, high-pitched, and may radiate. Mitral regurgitation is a high-pitched, blowing, harsh, systolic
murmur with radiation to the left axilla. The murmur associated with mitral stenosis is best heard with
the bell of the stethoscope at the apex while the client is placed in the left lateral position. It is a low-
frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a
cardiac infection. The murmur associated with pulmonic stenosis is often described as a harsh,
systolic murmur heard best over the pulmonic area with radiation to the neck.
Cognitive Level: Analyzing
Client Need Sub:

Question 18
Type: MCSA
During the cardiac assessment of a client, the nurse hears a loud rumbling during diastole that
increases toward the end of the sound. This sound is heard with the bell of the stethoscope over the
lower left sternal border. The nurse would suspect which of the following in this client?
1. Aortic stenosis
2. Tricuspid stenosis
3. Mitral regurgitation
4. Pulmonic stenosis
Correct Answer: 2
Rationale 1: The type of murmur heard with aortic stenosis occurs midsystole and is
crescendo-decrescendo.
Rationale 2: The sound heard in this scenario is most likely a murmur related to tricuspid stenosis.
Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound increases
towards the end of the sound.
Rationale 3: With mitral regurgitation, the sound is heard in systole and is continuous.
Rationale 4: With pulmonary stenosis, the midsystolic sound is heard over the right sternal border in
the second intercostal space.
Global Rationale: The type of murmur heard with aortic stenosis occurs midsystole and is
crescendo-decrescendo. The sound heard in this scenario is most likely a murmur related to
tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The
sound increases toward the end of the sound. With mitral regurgitation, the sound is heard in systole
and is continuous. With pulmonary stenosis, the midsystolic sound is heard over the right sternal
border in the second intercostal space.
Client Need Sub:
Question 19
Type: MCSA
The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year-old
client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above
the sternal angle when the client is at a 45 degree angle, and an enlarged liver. These findings are
most consistent with which of the following disorders?
1. Pulmonary edema
2. Left-sided heart failure
3. Myocardial infarction
4. Right-sided heart failure
Correct Answer: 4
Rationale 1: Left-sided heart failure results in pulmonary congestion and pulmonary edema as
blood backs up into the pulmonary system.
Rationale 2: Left-sided heart failure results in pulmonary congestion and pulmonary edema as
blood backs up into the pulmonary system.
Rationale 3: Heart failure may be caused by a myocardial infarction. However, the clinical
manifestations associated with heart failure are not always the result of a myocardial infarction.
Rationale 4: With right-sided heart failure, the right ventricle is ineffective as a pump, which leads
to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in
increased jugular vein distention. This is a reflection of the increased pressure in the right atrium.
Right-sided heart failure also results in peripheral edema and liver enlargement.
Global Rationale: Left-sided heart failure results in pulmonary congestion and pulmonary edema as
blood backs up into the pulmonary system. Heart failure may be caused by a myocardial infarction.
However, the clinical manifestations associated with heart failure are not always the result of a
myocardial infarction. With right-sided heart failure, the right ventricle is ineffective as a pump, which
leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results
in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium.
Right-sided heart failure also results in peripheral edema and liver enlargement.
Client Need Sub:
Question 20
Type: MCSA
The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery.
The nurse would suspect the client has developed which of the following disorders?
1. Mitral stenosis
2. Aortic regurgitation
3. Atrial septal defect
4. Stricture of the carotid
Correct Answer: 4
Rationale 1: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral stenosis,
there is often a murmur heard at the apical area with the client in left lateral position.
Rationale 2: Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With
aortic regurgitation, a murmur may be heard when the client is leaning forward, at the second
intercostal space.
Rationale 3: With an atrial septal defect, there is an opening between the right and left atrium.
Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at
the left sternal border at the second intercostal space.
Rationale 4: A bruit, which is a loud swishing or blowing sound, is most often associated with a
narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis.
Global Rationale: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral
stenosis, there is often a murmur heard at the apical area with the client in left lateral position.
Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic
regurgitation, a murmur may be heard when the client is leaning forward, at the second intercostal
space. With an atrial septal defect, there is an opening between the right and left atrium.
Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at
the left sternal border at the second intercostal space. A bruit, which is a loud swishing or blowing
sound, is most often associated with a narrowing or stricture of the carotid artery. The most
common cause for this is atherosclerosis.
Client Need Sub:
Question 21
Type: MCMA
The nurse is caring for a client admitted with a grade 3 heart murmur heard during systole.
The nurse would suspect which of the following cardiac conditions?
1. Mitral regurgitation
2. Mitral stenosis
3. Aortic stenosis
4. Pulmonic stenosis
5. Tricuspid stenosis
Correct Answer: 1,3,4
Rationale 1: Mitral regurgitation. A grade 3 murmur can be heard clearly and the nurse should
be able to categorize the murmur easily. The murmur associated with mitral regurgitation can be
heard during systole.
Rationale 2: Mitral stenosis. The murmur associated with mitral stenosis can be heard during
diastole.
Rationale 3: Aortic stenosis. Midsystolic murmurs are associated with semilunar valve disorders.
This murmur is heard during midsystole and this can be associated with aortic stenosis.
Rationale 4: Pulmonic stenosis. Midsystolic murmurs are associated with semilunar valve
disorders. This murmur is heard during midsystole and this can be associated with pulmonic
stenosis.
Rationale 5: Tricuspid stenosis. The murmur associated with tricuspid stenosis can be
heard during diastole.
Global Rationale: The murmur associated with mitral regurgitation can be heard during systole.
Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during
midsystole and this can be associated with pulmonic or aortic stenosis. The murmur associated with
mitral or tricusid stenosis can be heard during diastole. The murmur associated with tricuspid
stenosis can be heard during diastole.
Client Need Sub:

Question 22
Type: MCMA
The nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases.
The nurse would choose which of the following actions?
1. Refer the client to a plastic surgeon.
2. Document this finding as normal.
3. Document the finding and notify the healthcare provider.
4. Ask the client about any history of injuries to his ears.
5. Assess the client’s risk factors for coronary artery disease.
Rationale 1: Refer the client to a plastic surgeon. The client may have an increased risk for
developing coronary artery disease. At this point, the client does not need to be referred to a plastic
surgeon.
Rationale 2: Document this finding as normal. This is an abnormal finding and the client should
be carefully monitored for the development of coronary artery disease.
Rationale 3: Document the finding and notify the healthcare provider. The nurse should
document the finding, request information from the client regarding any injuries to the ears,
and notify the healthcare provider about the presence of the bilateral earlobe creases.
Rationale 4: Ask the client about any history of injuries to his ears. The nurse should determine
if the client has sustained any injuries to the ears that could account for the bilateral earlobe creases.
Rationale 5: Assess the client’s risk factors for coronary artery disease. The nurse should
assess the client for any other clinical manifestations and risk factors associated with coronary artery
disease.
Global Rationale: This is an abnormal finding and the client should be carefully monitored for the
development of coronary artery disease. The nurse should document the finding, request information
from the client regarding any injuries to the ears, and notify the healthcare provider about the
presence of the bilateral earlobe creases. The nurse should assess the client for any other clinical
manifestations and risk factors associated with coronary artery disease. At this point, the client does
not need to be referred to a plastic surgeon.

Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Question 23
Type: MCMA
The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the
following findings may be expected when compared to when the client was middle-aged?
1. Systolic murmur
2. Increased cardiac output
3. Increased systolic blood pressure
4. Increased stroke volume
5. Slight decrease in heart rate
Rationale 1: Systolic murmur. Systolic murmurs become more common as people age,
especially because of aortic stenosis.
Rationale 2: Increased cardiac output. In the healthy older adult, cardiac output remains relatively
stable.
Rationale 3: Increased systolic blood pressure. The client’s systolic blood pressure
may increase.
Rationale 4: Increased stroke volume. Stroke volume may increase slightly when the client is at
rest and during exercise.
Rationale 5: light decrease in heart rate. The healthy older adult may have an
insignificant decrease in heart rate.
Global Rationale: Systolic murmurs become more common as people age, especially because of
aortic stenosis. In the healthy older adult, cardiac output remains relatively stable. The older client’s
systolic blood pressure may increase. Stroke volume may increase slightly when the older client is at
rest and during exercise. The healthy older adult may have an insignificant decrease in heart rate.

Client Need Sub:
Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and

environmental variations in assessment techniques and findings.
Question 24
Type: MCSA
The nurse is assessing a client who is 7 months pregnant. The nurse would document which of
the following cardiac findings as normal in this client?
1. Increased systolic and diastolic blood pressures when standing
2. Point of maximal impulse palpated at fourth intercostal space and left of midclavicular line
3. Bradycardia
4. Diastolic murmur
Correct Answer: 2
Rationale 1: At this stage of the client’s pregnancy, the blood pressure should be normal
when compared to pre-pregnancy values.
Rationale 2: During pregnancy, the heart is displaced to the left and upward and so it would be
normal to palpate the point of maximal impulse left of the midclavicular line at the fourth intercostal
space.
Rationale 3: The pregnancy usually results in an increase in the client’s heart rate from pre-
pregnancy values.
Rationale 4: It is not normal to find a diastolic murmur.
Global Rationale: At this stage of the client’s pregnancy, the blood pressure should be normal when
compared to pre-pregnancy values. During pregnancy, the heart is displaced to the left and upward
and so it would be normal to palpate the point of maximal impulse left of the midclavicular line at the
fourth intercostal space. The pregnancy usually results in an increase in the client’s heart rate from
pre-pregnancy values. It is not normal to find a diastolic murmur.
Client Need Sub:


Question 25
Type: MCSA
The nurse is assessing a full-term African American newborn that is 18 hours old. The nurse would
document which of the following as a normal finding?
1. Lethargy
2. Heart rate 115–120
3. Bulging of the precordium
4. Pale conjunctiva
Correct Answer: 2
Rationale 1: The infant should be easily aroused and alert.
Rationale 2: The heart rate of a newborn initially may be as high as 175–180 beats per minute but
should decrease over the next 6 to 8 hours to about 115–120 beats per minute.
Rationale 3: Precordial bulging should always be evaluated and is never considered a

normal finding.
Rationale 4: The skin should demonstrate perfusion with pink quality in the nail beds,
mucous membranes, and conjunctiva regardless of the baby’s race.
Global Rationale: The infant should be easily aroused and alert. The heart rate of a newborn
initially may be as high as 175–180 beats per minute but should decrease over the next 6 to 8
hours to about 115–120 beats per minute. Precordial bulging should always be evaluated and is
never considered a normal finding. The skin should demonstrate perfusion with pink quality in the
nail beds, mucous membranes, and conjunctiva regardless of the baby’s race.
Client Need Sub:

Question 26
Type: MCSA
The nurse notes the pregnant client’s blood pressure has dropped from 122/70 taken during her
second month of pregnancy to 118/64 during her fifth month of pregnancy. Which of the
following actions by the nurse is most appropriate?
1. Assess for signs of hemorrhage.
2. Document the blood pressure as a normal finding .
3. Consult the healthcare provider.
4. Tell the client to come in the next day so the nurse can recheck her blood pressure.
Correct Answer: 2
Rationale 1: This small drop in blood pressure is expected and the nurse does not need to assess
the client for signs of hemorrhage.
Rationale 2: During pregnancy, there is a substantial increase in cardiac workload secondary to the
increase in blood volume. Despite this, the systolic and diastolic blood pressures may decrease
during the first half of pregnancy. This is secondary to the peripheral vasodilatation. During the
second half of the pregnancy, the blood pressure will return to previous pre-pregnancy levels.
Rationale 3: The healthcare provider does not need to be consulted because this is a normal
finding.
Rationale 4: The client does not need to return to have her blood pressure checked on the following
day.
Global Rationale: This small drop in blood pressure is expected and the nurse does not need to
assess the client for signs of hemorrhage. During pregnancy, there is a substantial increase in
cardiac workload secondary to the increase in blood volume. Despite this, the systolic and diastolic
blood pressures may decrease during the first half of pregnancy. This is secondary to the peripheral
vasodilatation. During the second half of the pregnancy, the blood pressure will return to previous
pre-pregnancy levels. The healthcare provider does not need to be consulted because this is a
normal finding. The client does not need to return to have her blood pressure checked on the
following day.
Client Need Sub:


Question 27
Type: MCSA
The student nurse is speaking with a nurse regarding the objectives of Healthy People 2020.
Which of the following statements by the student nurse indicates that the student nurse requires
further education regarding these objectives?
1. “Parents of school-aged children really need to be educated about the importance of treating
strep throat.”
2. “African Americans really need to be educated about the symptoms associated

with hypertension.”
3. “People who smoke are twice as likely to die from a heart attack when compared to those who
don’t smoke.”
4. “African Americans can benefit greatly from education aimed at increasing their
understanding about the importance of exercise.”
Correct Answer: 2
Rationale 1: It is appropriate to educate parents of school-aged children about the importance of

screening for and treating strep in their children. This can help prevent rheumatic fever and the
valvular problems that are associated with this infection.
Rationale 2: African Americans can benefit from blood pressure screening activities. Hypertension is
often present without any symptoms so education about symptoms will not be particularly beneficial.
Rationale 3: Smokers have double the mortality rate from myocardial infarction than nonsmokers.
Rationale 4: The impact of hypertension, diabetes, and obesity is particularly noted in African
Americans. Exercise can reduce the risks for cardiovascular disease by promoting healthy
weight, maintaining healthy blood pressure, and reducing the risk for development of diabetes.
Global Rationale: It is appropriate to educate parents of school-aged children about the importance
of screening for and treating strep in their children. This can help prevent rheumatic fever and the
valvular problems that are associated with this infection. African Americans can benefit from blood
pressure screening activities. Hypertension is often present without any symptoms so education
about symptoms will not be particularly beneficial. Smokers have double the mortality rate from
myocardial infarction than nonsmokers. The impact of hypertension, diabetes, and obesity is
particularly noted in African Americans. Exercise can reduce the risks for cardiovascular disease by
promoting healthy weight, maintaining healthy blood pressure, and reducing the risk for
development of diabetes.

Client Need Sub:
Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the
Question 28
Type: MCMA
The client is 3 months pregnant. The nurse recently reviewed the objectives of Healthy People
2020 regarding pregnant women. Which of the following statements by the client indicates
adequate education has occurred according to the objectives?
1. “I never got my rubella vaccination so I’ve been staying away from my niece who has rubella.”
2. “I stopped taking Accutane for my acne before we started trying to get pregnant.”
3. “I have been so careful about taking my insulin now that I’m pregnant.”
4. “I have just one glass of wine each evening.”
5. “I had to change to a different medication to prevent my seizures before we got pregnant.”
Rationale 1: “I never got my rubella vaccination so I’ve been staying away from my niece who
has rubella.” Pregnant females who have not had or been immunized against rubella must avoid
contraction of the virus during the first trimester of pregnancy.
Rationale 2: “I stopped taking Accutane for my acne before we started trying to get
pregnant.” The use of Accutane during pregnancy can increase the risk of having a child
with congenital heart defects.
Rationale 3: “I have been so careful about taking my insulin now that I’m pregnant.” Females
with diabetes mellitus have an increased risk of having a child with a heart defect. Careful
regulation of the diabetes before and in early pregnancy can reduce the risk.
Rationale 4: “I just have one glass of wine each evening.” It is not appropriate to drink alcohol
during pregnancy because it increases the risk of having a child with birth defects.
Rationale 5: “I had to change to a different medication to prevent my seizures before we got

pregnant.” Some anti-seizure medications can increase the risk of having a child with a heart
defect.
Global Rationale: Pregnant females who have not had or been immunized against rubella must
avoid contraction of the virus during the first trimester of pregnancy. The use of Accutane during
pregnancy can increase the risk of having a child with congenital heart defects. Females with
diabetes mellitus have an increased risk of having a child with a heart defect. Careful regulation of
the diabetes before and in early pregnancy can reduce the risk. It is not appropriate to drink alcohol
during pregnancy because it increases the risk of having a child with birth defects. Some anti-seizure
medications can increase the risk of having a child with a heart defect.
Client Need Sub:
Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the
Question 29
Type: MCMA
The Emergency Department nurse determines that the client may be having a myocardial infarction.
Which of the following pieces of information indicate that the client is experiencing an acute
cardiovascular problem?
1. Blood pressure has dropped from normal and is 90/52.
2. Apical heart rate is 114 beats per minute.
3. Skin is flushed and warm.
4. Respiratory rate is 28 per minute.
5. The client is complaining of a headache.
Rationale 1: Blood pressure has dropped from normal is 90/52. This client is hypotensive and
this suggests that an acute cardiovascular problem may be occurring.
Rationale 2: Apical heart rate is 114 beats per minute. The client is tachycardic and this
is indicative of an acute cardiovascular problem.
Rationale 3: Skin is flushed and warm. Warm, flushed skin is not necessarily associated with an
acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an
acute cardiovascular problem.
Rationale 4: Respiratory rate is 28 per minute. This client is tachypneic and this is associated with
an acute cardiovascular problem.
Rationale 5: The client is complaining of a headache. A headache is not necessarily a symptom

of an acute cardiovascular problem.
Global Rationale: This client is hypotensive and this suggests that an acute cardiovascular problem
may be occurring. The client is tachycardic and this is indicative of an acute cardiovascular problem.
Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis,
blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem. This client
is tachypneic and this is associated with an acute cardiovascular problem. A headache is not
necessarily a symptom of an acute cardiovascular problem.
Client Need Sub:
Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical
assessment of the cardiovascular system.
Question 30
Type: MCSA
The client has been admitted to the Coronary Care Unit with a myocardial infarction. Which of
the following statements by the client indicate that adequate learning has occurred?
1. “I’m just sick to my stomach because I ate something that didn’t agree with me.”
2. “I think I must have given myself a little too much insulin this morning.”
3. “I’ve been breathing fast and my heart’s been racing because my heart’s not working right.”
4. “Just give me something for the nausea and I can go home.”
Correct Answer: 3
Rationale 1: The client believes that the nausea is unrelated to an acute cardiovascular event such
as a myocardial infarction.
Rationale 2: The client believes that his symptoms are related to hypoglycemia and will require
education about the seriousness of his heart condition.
Rationale 3: The client is correct when he states that his heart is not working well and his respiratory
rate and heart rate are up because of it.
Rationale 4: The client will be unable to go home until after he is stabilized and medically fit to return
home.
Global Rationale: The client does not understand the importance of the symptoms that he is
experiencing. The client believes that the nausea is unrelated to an acute cardiovascular event
such as a myocardial infarction. The client believes that his symptoms are related to hypoglycemia
and will require education about the seriousness of his heart condition. The client is correct when
he states that his heart is not working well and his respiratory rate and heart rate are up because of
it. The client will be unable to go home until after he is stabilized and medically fit to return home.
Client Need Sub:
Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical
assessment of the cardiovascular system.

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1. “It results from the closure of the semilunar valves.”

3. “It results from the closure of the atrioventricular valves.”

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Standard Text: Select the correct area on the image.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Correct Answer: 5904 mL per minute.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Standard Text: Select the correct area on the image.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.2: Recognize landmarks that guide assessment of the

Standard Text: Select the correct area on the image.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.2: Recognize landmarks that guide assessment of the

Standard Text: Select all that apply.

1. “I have been stressed out since my divorce last year.”

2. “I’m what you call a Type C personality.”

4. “On my new diet, I can eat only grains and vegetables.”

5. “I think about my job all of the time.”

Correct Answer: 1,3,4,5

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

1. “I was diagnosed with hypothyroidism about 5 years ago.”

4. “My total cholesterol has always been around 170.”

Rationale 2: Hypertension, not hypotension, is associated with the development of cardiovascular

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

1. “I couldn’t catch my breath.”

2. “My chest didn’t actually ever hurt.”

4. “I got so sick to my stomach.”

Rationale 3: In males, the pain of MI is often accompanied by diaphoresis.

Rationale 4: In males, the pain of MI is often accompanied by nausea.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

2. “Have you ever been diagnosed with rheumatic fever?”

3. “Do you smoke or are you exposed to secondhand smoke?”

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Standard Text: Select all that apply.

4. Client gown and a drape