ANSWERS AND RATIONALES

1. Answer: C
Rationale: The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme
levels, especially the MB sub-unit which is cardio-specific, begin to rise
in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the
occurrence of the infarct. They are therefore most reliable in assisting
with early diagnosis. The cardiac markers elevate as a result of
myocardial tissue damage.

2. Answer: C
Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120
X = 12 minims. The nurse will administer 12 minims intravenously
equivalent to 8mg Morphine Sulfate

3. Answer: B
This is a typical early finding after a myocardial infarct because of the
altered contractility of the heart. The other choices are not typical of
MI.

4. Answer: D
A cardiac glycoside such as digitalis increases force of cardiac
contraction, decreases the conduction speed of impulses within the
myocardium and slows the heart rate.

5. Answer: B
Restriction of sodium reduces the amount of water retention that reduces
the cardiac workload

6. Answer: B
Pulmonary congestion and edema occur because of fluid extravasation from
the pulmonary capillary bed, resulting in difficult breathing. Left-sided
heart failure creates a backward effect on the pulmonary system that
leads to pulmonary congestion.

7. Answer: B
Rationale: The primary goal of therapy for the client with pulmonary
edema or heart failure is increasing cardiac output. Pulmonary edema is
an acute medical emergency requiring immediate intervention.

8. Answer: A
Rationale: By the second day of hospitalization after suffering
a Myocardial Infarction, Clients are able to perform care without chest
pain

9. Answer: D
Rationale: Anoxia of the myocardium occurs in myocardial infarction.
Oxygen administration will help relieve dyspnea and cyanosis associated
with the condition but the major purpose is to increase the oxygen
concentration in the damaged myocardial tissue.

10. Answer: B
Rationale: Clients that present with mitral stenosis often have a history
of rheumatic fever or bacterial endocarditis.

11. Answer: B
Rationale: The ECG reading of a client who had myocardial ischemia
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would reveal an inverted T wave and SST segment elevation. The ECG
tracing of a client with myocardial injury is characterized by a
symmetric and peaked T wave and at least 1 mm ST segment elevation
while myocardial infarction will show an abnormal or pathologic Q wave
that develops within 1-3 days after MI.

12. Answer: A
Rationale: Managing hypertension is the priority for the client with
hypertension. Clients with hypertension frequently do not experience pain,
deficient volume or impaired skin integrity. It is the asymptomatic nature
of hypertension that makes it so difficult to treat.

13. Answer: D
Rationale: There is a potential alteration in renal perfusion manifested by
decreased urine output. The altered renal perfusion may be related to
renal artery embolism, prolonged hypotension, or prolonged aortic cross-
clamping during the surgery.

14. Answer: A
Rationale: An increased in LDL cholesterol concentration has been
documented at risk factor for the development of atherosclerosis. LDL
cholesterol is not broken down into the liver but is deposited into the
wall of the blood vessels.

15. Answer: B
Rationale: Morphine is a central nervous system depressant used to relieve
the pain associated with myocardial infarction, it also decreases
apprehension and prevents cardiogenic shock.

16. Answer: C Rationale: When diuretics are taken in the morning, client
will void frequently during daytime and will not need to void frequently
at night.

17. Answer: D
Rationale: Administration of Intravenous Nitroglycerin infusion requires
pump for accurate control of medication.

18. Answer: D
Rationale: When mitral stenosis is present, the left atrium has difficulty
emptying its contents into the left ventricle because there is no valve to
prevent back ward flow into the pulmonary vein; the pulmonary
circulation is under pressure.

19. Answer: C
Rationale: Wheat cereal has low sodium content.

20. Answer: D
Rationale: Seeing yellow spots and colored vision are common symptoms of
digitalis toxicity

21. Answer: D
Rationale: When the heart rate is above 60 beats per minute and below
10 beats per minute, digoxin therapy is deemed effective. However, if too
much digoxin was administered to the client, Mobitz II heart block may
be present.

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22. Answer: C
Rationale: The client with left-sided heart failure usually has pulmonary
congestion, orthopnea, hemoptysis and experiences dyspnea and coughing.
Right sided heart failure is characterized by hepatomegaly, edema, ascites
and distended neck veins. Right sided heart failure is another complication
of cardiomyopathy.

23. Answer: D
Rationale: Patients with Arterial Occlusive Disease have decreased
perfusion of tissues. By placing the patient in a dependent position,
blood flow to the lower extremities is enhanced, and, therefore, the
nursing diagnosis for this intervention would be Altered Tissue Perfusion.

24. Answer: A
Rationale: A "tet" spell is when the child is having difficulty meeting
oxygen demands. The knee chest position reduces venous blood return from
the lower extremities and increases vascular resistance to divert blood
flow to the pulmonary artery.

25. Answer: B
Rationale: The major complication of thromboembolytic therapy is
hemorrhage, and the antidote for this is Amicar, which aids in the
stoppage of bleeding by inhibiting plasminogen, which inhibits
thrombolysis. This drug should be available for any patient on this type
of thromboembolytic therapy. Protamine Sulfate and Vitamin K are the
antidotes for Heparin and Coumadin, respectively. Heparin is not correct,
as it is an anticoagulant.

26. Answer: A
Rationale: Straining or bearing down activities can cause vagal stimulation
that leads to bradycardia. Use of stool softeners promote easy bowel
evacuation that prevents straining or the valsalva maneuver.

27. Answer: B
Rationale: Clients that present with mitral stenosis often have a history
of rheumatic fever or bacterial endocarditis.

28. Answer: D
Rationale: Heartburn is a burning sensation caused by regurgitation of
gastric contents that is best relieved by sleeping position, eating small
meals, and not eating before bedtime.

29. Answer: A
Rationale: Polycythemia occurs as a physiological reaction to chronic
hypoxemia which commonly occurs in clients with Tetralogy of Fallot.
Polycythemia and the resultant increased viscosity of the blood increase
the risk of thromboembolic events. Cerebrovascular accidents may occur.
Signs and symptoms include sudden paralysis, altered speech, extreme
irritability or fatigue, and seizures.

30. Answer: C
Rationale: PTCA (percutaneous transluminal coronary angioplasty) is
performed to improve coronary artery blood flow in a diseased artery. It
is performed during a cardiac catheterization. Aorta coronary bypass
Graft is the surgical procedure to repair a diseased coronary artery.

31. Answer: B
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Rationale: Administering stool softeners every day will prevent straining

on defecation which causes the Valsalva maneuver. If constipation occurs
then laxatives would be necessary to prevent straining. If straining on
defecation produced the valsalva maneuver and rhythm disturbances
resulted then antidysrhythmics would be appropriate.

32. Answer: D
Rationale: “I smoke 1 1/2 packs of cigarettes per day.” Smoking has
been considered as one of the major modifiable risk factors for coronary
artery disease. Exercise and maintaining normal serum cholesterol levels
help in its prevention.

33. Answer: D
Rationale: The client should be advised by the nurse to avoid contact
sports. This will prevent trauma to the area of the pacemaker generator.

34. Answer: B
Rationale: Canned foods are generally rich in sodium content as salt is
used as the main preservative.

35. Answer: D
Rationale: Angina pectoris is caused by myocardial ischemia related to
decrease coronary blood supply. Giving nitroglycerine will produce coronary
vasodilation that improves the coronary blood flow in 3 – 5 mins. If the
chest pain is unrelieved, after three tablets, there is a possibility of
acute coronary occlusion that requires immediate medical attention.

36. Answer: D
Rationale: Administration of Intravenous Nitroglycerin infusion requires
pump for accurate control of medication.

37. Answer: D
Rationale: A cardiac glycoside such as digitalis increases force of cardiac
contraction decreases the conduction speed of impulses within the
myocardium and slows the heart rate.

38. Answer: D
Rationale: Ascending limb of the loop of Henle. This is the site of action
of Lasix being a potent loop diuretic.

39. Answer: B
Rationale: Dyspnea on exertion. Pulmonary congestion and edema occur
because of fluid extravasation from the pulmonary capillary bed, resulting
in difficult breathing. Left-sided heart failure creates a backward effect
on the pulmonary system that leads to pulmonary congestion.

40. Answer: B
Rationale: Restriction of sodium reduces the amount of water retention
that reduces the cardiac workload

41. Answer: B
Rationale: 2000 calories. There are 9 calories in each gram of fat and 4
calories in each gram of carbohydrate and protein.

42. Answer: D
Rationale: Increased pulse rate
Fever causes an increase in the body’s metabolism, which results in an
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increase in oxygen consumption and demand. This need for oxygen

increases the heart rate, which is reflected in the increased pulse rate.
Increased BP, chest pain and shortness of breath are not typically noted
in fever.

43. Answer: B
Rationale: Refocus the conversation on his fears, frustrations and anger
about his condition. This provides the opportunity for the client to
verbalize feelings underlying behavior and helpful in relieving anxiety.
Anxiety can be a stressor which can activate the sympathoadrenal
response causing the release of catecholamines that can increase cardiac
contractility and workload that can further increase myocardial oxygen
demand.

44. Answer: B
Rationale: Elevated STsegments This is a typical early finding after
a myocardial infarct because of the altered contractility of the heart.
The other choices are not typical of MI.

45. Answer: C
Rationale: CK-MB. The cardiac marker, Creatinine phosphokinase (CPK)
isoenzyme levels, especially the MB sub-unit which is cardio-specific,
begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48
hours after the occurrence of the infarct. They are therefore most
reliable in assisting with early diagnosis. The cardiac markers elevate as
a result of myocardial tissue damage.

46. Answer: B
Rationale: Relieves pain and decreases level of anxiety. Morphine is a
specific central nervous system depressant used to relieve the pain
associated with myocardial infarction. It also decreases anxiety and
apprehension and prevents cardiogenic shock by decreasing myocardial
oxygen demand.

47. Answer: A
Rationale: 60 microdrops/minute
2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute

48. Answer: D
Rationale: The primary goal in the management of CVA is to improve
cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the
prevention of recurrent or embolic stroke but is not used in the acute
management of a completed stroke as it may lead to bleeding.

49. Answer: D
Rationale: Angiography involves the threading of a catheter through an
artery which can cause trauma to the endothelial lining of the blood
vessel. The platelets are attracted to the area causing thrombi formation.
This is further enhanced by the slowing of blood flow caused by flexion
of the affected extremity. The affected extremity must be kept straight
and immobilized during the duration of the bedrest after the procedure.
Ice bag can be applied intermittently to the puncture site.

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50. Answer: C
Rationale: Using ratio and proportion 8 mg/10 mg = X minims/15 minims
10 X= 120 X = 12 minims The nurse will administer 12 minims
intravenously equivalent to 8mg Morphine Sulfate

51. Answer: D
Rationale: Angina pectoris is caused by myocardial ischemia related to
decreased coronary blood supply. Giving nitroglycerine will produce
coronary vasodilation that improves the coronary blood flow in 3 – 5
mins. If the chest pain is unrelieved, after three tablets, there is a
possibility of acute coronary occlusion that requires immediate medical
attention.

52. Answer: A
Rationale: Straining or bearing down activities can cause vagal stimulation
that leads to bradycardia. Use of stool softeners promotes easy bowel
evacuation that prevents straining or the valsalva maneuver.

53. Answer: D
Rationale: The client should be advised by the nurse to avoid contact
sports. This will prevent trauma to the area of the pacemaker generator.

54. Answer: B
Rationale: Inotropic effect of drugs on the heart causes increase force of
its contraction. This increases cardiac output that improves renal
perfusion resulting in an improved urine output.

55. Answer: C
Rationale: The clients who are misdiagnosed concerning MI’s usually
present with atypical symptoms. They tend to be female, be younger than
55 years old, be members of a minority group, and have normal
electrocardiograms.

56. Answer: D
Rationale: Hyperkalemia will cause a peaked T-wave; therefore, the nurse
should check this laboratory data.

57. Answer: A
Rationale: Medical client problems indicate the nurse and the physician
must collaborate to care for the client; the client must have medications
for heart failure.

58. Answer: D
Rationale: Cold, clammy skin is an indicator of cardiogenic shock, which
is a complication of MI and warrants immediate intervention.

59. Answer: A
Rationale: The second intercostal space, right sterna notch, is the area on
the chest where the aorta can best be heard opening and closing.

60. Answer: A
Rationale: The recommended diet for CAD is low fat, low cholesterol, and
high fiber. The diet described is a diet that is low in fat and
cholesterol.

61. Answer: A
Rationale: This is a medical emergency; the nurse should stay with the
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client, keep him calm, and call the nurses’ station to notify the health-
care provider. Cardiac output declines with each contraction as the
pericardial sac constricts the myocardium.

62. Answer: A
Rationale: This potassium level is below normal levels; hypokalemia can
potentiate digoxin toxicity and lead to cardiac dysrhythmias.

63. Answer: B
Rationale: Decreased cardiac output is responsible for all the
signs/symptoms associated with CHF and eventually causes death, which is
why it is the priority problem.

64. Answer: A
Rationale: The chest pain for an MI usually is described as an elephant
sitting on the chest or a belt squeezing the substernal mid-chest, often
radiating to the jaw or left arm.

65. Answer: D
Rationale: BNP is a hormone released by the heart muscle in response to
changes in blood volume and is used to diagnose and grade heart failure.

66. Answer: C
Rationale: Having the client lean forward and to the left uses gravity to
force the heart nearer to the chest wall, which allows the friction rub
to be heard.

67. Answer: D
Rationale: Assessment is the first step in the nursing process and should
be implemented first; chest pain is priority.

68. Answer: C
Rationale: NPO decreases the chance of aspiration in case of emergency.
In addition, if the client has just had a meal, the blood supply will be
shunted to the stomach for digestion and away from the heart, perhaps
leading to an inaccurate test result.

69. Answer: B
Rationale: The client removes the old patch before placing the new one.
This behavior indicates the client understands the discharge teaching.

70. Answer: A
Rationale: This dosage is 10 times the normal dose for a client with CHF.
This dose is potentially lethal.

71. Answer: C
Rationale: An audible S3 indicates the client is developing left-sided heart
failure and needs to be assessed immediately.
72. Answer: C
Rationale: Cell phones may interfere with the functioning of the ICD if
they are placed too close to it.

73. Answer: B
Rationale: Without a heart transplant, this client will end up in end-
stage heart failure. A transplant is the only treatment for a client with
dilated cardiomyopathy.

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74. Answer: B
Rationale: The nurse must first determine if the client has a pulse.
Pulseless ventricular tachycardia is treated as ventricular fibrillation.
Stable ventricular tachycardia is treated with medications.

75. Answer: A
Rationale: Cardioversion involves the delivery of a timed electrical
current. The electrical impulse discharges during ventricular depolarization
and therefore there might be a short delay. The nurse should wait until
discharges.

76. Answer: A
Rationale: The DASH diet has proved beneficial in lowering blood pressure.
It recommends eating a diet high in vegetables and fruits.

77. Answer: D
Rationale: Orthostatic hypotension may occur when the blood pressure is
decreasing and may lead to dizziness and light-headedness so the client
should change position slowly.

78. Answer: B
Rationale: Rapid weight gain—for example, 2 kg in 1–2 days—indicates
that the loop diuretic is not working effectively; 2 kg equals 4.4 lbs; 1 L
of fluid weighs l kg.

79. Answer: A
Rationale: The decreased oxygen over time causes the loss of hair on top
of feet and ascends both legs.

80. Answer: C
Rationale: Numbness and tingling are paresthesia, which is a sign of a
severely decreased blood supply to the lower extremities.

81. Answer: B
Rationale: The nurse should question administering the beta blocker if the
B/P is low because this medication will cause the blood pressure to drop
even lower, leading to hypotension.

82. Answer: D
Rationale: After the surgery, the client’s legs will be elevated to help
decrease edema. The surgery has corrected the decreased blood supply to
the lower legs.

83. Answer: C
Rationale: Walking promotes the development of collateral circulation to
ischemic tissue and slows the process of atherosclerosis.

84. Answer: A
Rationale: An absent pulse is not uncommon in a client diagnosed with
arterial occlusive disease, but the nurse must ensure that the feet can be
moved and are warm, which indicates adequate blood supply to the feet.

85. Answer: C
Rationale: This is the scientific rationale why diabetes mellitus is a
modifiable risk factor for atherosclerosis.

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86. Answer: D
Rationale: Fluids will help flush the contrast dye out of the body and
help prevent kidney damage.

87. Answer: C
Rationale: Intermittent claudication is a sign of generalized atherosclerosis
and is a marker of atherosclerosis.

88. Answer: D
Rationale: This response explains in plain terms why the client’s legs hurt
from atherosclerosis.

89. Answer: B
Rationale: A systolic bruit over the abdomen is a diagnostic indication of
an Abdominal Aortic Aneurysm.

90. Answer: A
Rationale: The client has a foot ulcer, therefore the protective lining of
the body—the skin— has been impaired.

91, Answer: B
Rationale: This is the classic symptom of arterial occlusive disease.

92. Answer: C
Rationale: Angiotensin-converting enzyme (ACE) inhibitors prevent the
conversion of angiotensin I to angiotensin II, and this, in turn, prevents
vasoconstriction and sodium and water retention.

93. Answer: D
Rationale: The leg dressing needs to be assessed for hemorrhaging or
signs of infection.

94. Answer: B
Rationale: The client needs to be taught ways to lower the cholesterol
level.

95. Answer: C
Rationale: Baked, broiled, or grilled meats are recommended: a plain
baked potato is appropriate; and skim milk is low in fat—so this meal is
appropriate for a low-fat, low cholesterol diet.

96. Answer: B
Rationale: Only about two-fifths of clients with AAA have symptoms; the
remainder is asymptomatic.

97. Answer: A
Rationale: Low back pain is present because of the pressure of the
aneurysm on the lumbar nerves; this is a serious symptom, usually
indicating that the aneurysm is expanding rapidly and about to rupture.

98. Answer: B
Rationale: The client must have 30 mL urinary output every hour. Clients
who are post-operative AAA are at high risk for renal failure because of
the anatomical location of the AAA near the renal arteries.

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99. Answer: A
Rationale: Assessment is the first part of the nursing process and is the
first intervention the nurse should implement.

100. Answer: B
Rationale: Increased pressure in the abdomen secondary to a tap water
enema could cause the abdominal aortic aneurysm to rupture.

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