1. The clinic nurse is teaching the client at risk for developing arteriosclerosis.

The nurse should teach the client that the dietary therapy to decrease homo-
cysteine levels includes eating foods rich in which nutrient?
A. Monosaturated fats
B. B complex Vitamins
C. Vitamin C
D. Calcium

ANSWER: B

A. Monosaturated fats are included in a healthy diet but have not been found to affect the
homocysteine levels.
B. Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich
in B-complex vitamins, especially folic acid, have been found to lower serum homoeystelne
levels.
C. Vitamin C is included in a healthy diet and enhances immune system functions but has not been
found to affect the homocysteine levels.
D. Calcium is important for bone health but has not been found to affect the homocysteinc levels.

2. The client’s BP is being taken at a screening clinic. Which client statement to

the nurse demonstrates awareness of having a risk factor for hypertension?
A. “My doctor told me my body mass index is 23 and my blood pressure is 118/70.”
B. “I usually have a glass of wine to unwind when I come home from work.”
C. “I plan to get my blood pressure checked more often, as I am African American.”
D. “I have colds during the winter, so I plan to get the influenza vaccine every year.”

ANSWER: C

A. A BMI of 25 or higher is considered a risk factor for hypertension. A BMI of 23 is normal. A BP of

118/70 is within normal range for an adult.
B. Excessive alcohol intake is a risk factor for hypertension; consuming two glasses of wine daily
increases the risk for hypertension.
C. Being African American is a known risk factor for hypertension. Starting to have the BP taken
more often demonstrates awareness of having a risk factor for hypertension.
D. Having frequent colds and taking the influenza vaccine does not increase the risk for
hypertension. Medications for treating colds, if taken frequently, can increase the risk for
hypertension.
3. The nurse has prepared medications for a 75-year-old client with
hypertension. The nurse notes that the client has an elevated serum
potassium level. Which medication is most important for the nurse to address
with the HCP before administration?

ANSWER: A

A. Hyperkalemia can occur as a side effect to lisinopril (Prinivil, Zestril), an ACE inhibitor. The HCP
should be notified prior to administration. The drug or dose may need to be changed; 40 mg is
the maximum daily dose for an elderly client.
B. Metoprolol (Lopressor), a beta adrenergic blocker, can increase serum creatinine and BUN levels
and cause hypoglycemia. There is no information in the stem about these levels.
C. Atorvastatin (Lipitor), an antilipidemic agent, lowers LDL levels; it has no effect on serum
potassium levels.
D. Sertraline (Zoloft), an SSRI, is used in treating anxiety or depression. 15 has no effect on serum
potassium levels. It may produce hyponatremia in older adults.

4. The nurse completes discharge teaching for the client with chronic stage 2
hypertension. Which statement by the client indicates that teaching was
effective?
A. “I will limit my intake of potassium by eating bananas only once a week.”
B. “1 will start a rigorous exercise program to lose this excess weight.”
C. “I will call my doctor immediately if I have sudden vision changes.”
D. “I will strive to maintain my body mass index (BMI) at 32.”

ANSWER: C
 A. Reduced intake of dietary potassium is a contributory factor associated with malignant
hypertension and should not be limited unless serum potassium levels are elevated. Sodium, not
potassium, should be limited with hypertension.
B. Clients with hypertension are advised to gradually increase to regular physical activity, and
should avoid sudden rigorous exercise programs.
C. Teaching is effective if the client states to call the HCP immediately if experiencing vision
changes. Sudden vision changes may be associated with stroke, a complication of hypertension.
D. A BMI of 32 is obese. Obesity is a contributing factor of hypertension and is defined as a BMI
greater than 30.

5. The nurse is taking the BP on multiple clients. Which reading warrants the
nurse notifying the HCP because the client’s MAP is abnormal?
A. 94/60 mm Hg
B. 98/36 mm Hg
C. 110/50 mm Hg
D. 140/78 mm Hg

ANSWER: B

6 . The nurse is assessing the client. At which area should the nurse place the
stethoscope to best auscultate the client’s murmur associated with mitral
regurgitation?
 A. Line A
B. Line B
C. Line C
D. Line D

ANSWER: D

A. Line A points to the aortic valve and would be associated with aortic stenosis, not mitral
regurgitation.
B. Line B points to the pulmonic valve and is not the valve to assess for mitral regurgitation.
C. Line C points to the tricuspid valve and is not the valve to assess for mitral regurgitation.
D. Mitral regurgitation is heard at the location of the mitral valve (line D) and should be
auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line.
The bell is used to auscultate low-pitched sounds.

7. The new nurse is experiencing difficulty hearing the client’s heart sounds
during auscultation and consults an experienced nurse. Which techniques
should the experienced nurse recommend to help identify the heart sounds
correctly? Select all that apply.
A. Auscultate over the client’s gown
B. Auscultate from the left side of the client
C. Ask the client to sit and lean forward
D. F eel the radial pulse while listening to heart sounds
E. Turn the client to the left side-lying position

ANSWER: C, D, E

A. Heart sounds are more difficult to auscultate through clothing; auscultate only under the gown.
B. Auscultating from the right side, not the left, allows stretching of the stethoscope across the
chest and reduces interference from the tubing.
C. The experienced nurse should recommend having the client lean forward during auscultation
because this position brings the heart closer to the chest wall and accentuates sounds from the
aortic and pulmonic areas.
 D. The experienced nurse should recommend feeling the pulse beat and listening at the same time
because it helps to focus on the rhythm and sounds, and aids in filtering extraneous stimuli.
E. The experienced nurse should recommend a left side-lying position during auscultation of heart
sounds; this brings the heart closer to the chest wall and accentuates sounds produced at the
mitral area.

8. At 0745 hours, the nurse is informed by the HCP that a cardiac

catheterization is to be completed on the client at 1400 hours. Which
intervention should be the nurse’s priority?
A. Place the client on NPO (nothing per mouth) status.
B. Teach the client about the cardiac catheterization.
C. Start an intravenous (IV) infusion of 0.9% NaCl.
D. Witness the client’s signature on the consent form.

ANSWER: A

A. A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine
position. The client is usually sedated with medication, such as midazolam, during the
procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure.
B. Because of the time element, NPO status should be initiated first, and then teaching should
occur.
C. To avoid administering too much fluid to the cardiac client, the saline infusion is usually only
started just prior to the client leaving the unit for the procedure.
D. A consent form should be signed after the cardiologist has spoken with the client.

9. While preparing the client for a computed tomography angiography (CTA),

the client asks the nurse what the test Will entail. Which should be the nurse’s
correct response?
A. “A CTA uses magnetic fields to visualize the major vessels Within your body.”
B. “A CTA is an invasive procedure that requires a small incision into an artery.”
C. “A CTA is a quick procedure that requires anesthesia for about 20 minutes.”
D. “A CTA is a scan that includes a contrast dye injection to visualize your arteries.”

ANSWER: D

A. A CTA uses X-ray beams, not magnetic fields, to visualize vessels.

B. A CTA is a noninvasive procedure and does not require any incisions.
C. CTA does not require anesthesia-
D. The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye
to yield a 3-dimensional image of the arteries.
10. The nurse reviews the client’s laboratory results exhibited. Which
findings, indicative of an MI, should the nurse report to the HCP? Place an X on
each laboratory finding indicative of an MI.

The CK—MB band is specific to myocardial cells and increases with myocardial injury. Cardiospecific
troponins (troponin T, cTnT, and troponin T, cTnI) are released into circulation after myocardial injury,
are highly specific indicators of MI, and have greater sensitivity and specificity than CK—MB.

11. The client is admitted with an ACS. Which should be the nurse’s priority
assessment?
A. Pain
B. Blood pressure
C. Heart rate
D. Respiratory rate

ANSWER: A
 A. The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not
receiving adequate oxygen and blood flow (perfusion).
B. BP is a response stemming from the lack of perfusion but is not the priority assessment.
C. HR is a response stemming from the lack of perfusion but is not the priority assessment-
D. Respiratory rate is a response stemming from the lack of perfusion but is not the priority
assessment.

12. The client with a left anterior descending (LAD) 90% blockage has
crushing chest pain that is unrelieved by taking sublingual nitroglycerin.
Which ECG finding is most concerning and should alert the nurse to
immediately notify the HCP?
A. Q waves
B. Flipped T waves
C. Peaked T waves
D. ST segment elevation

ANSWER: D

A. The presence of Q waves indicates an M1 over 24 hours old.

B. Flipped T waves indicate myocardial ischemia.
C. Peaked T waves may indicate hyperkalemia and are concerning, but ST segment elevation is
more concerning.
D. The nurse should be most concerned about ST elevation because it indicates an evolving MI.

13. The nurse observes sinus tachycardia with new-onset ST segment

elevation on the ECG monitor of the client reporting chest pain. Which should
be the nurse’s priority intervention?
A. Draw blood for cardiac enzymes STAT
B. Call the cardiac catheterization laboratory
C. Apply 1 inch of nitroglycerin paste topically
D. Apply 4 liters of oxygen via nasal cannula

ANSWER: D

A. Cardiac enzymes would be a likely intervention but the second intervention.

B. Cardiac catheterization would be likely intervention but the third intervention respectively.
C. Topical nitroglycerin is never given in an acute situation because its route has a much slower
rate of absorption.
D. The nurse’s priority intervention should be to increase oxygen to the heart muscle.
14. The nurse assesses the client returning from a coronary angiogram in
which the femoral artery approach was used. The client’s baseline BP during
the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm.
Which finding should alert the nurse to a potential complication?
A. BP 154/78 mm Hg
B. Pedal pulses palpable at +1
C. Left groin soft to palpation with 1 cm ecchymotic area
D. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm

ANSWER: D

A. A slight elevation of BP could be related to pain at the incision site. It is not indicative of a
complication without additional information.
B. Usually pulses are palpable at +2, but without additional baseline information on the client’s
pulses, this warrants monitoring but is not indicative in itself of a complication.
C. A soft groin area where the puncture site is located is a normal finding- Ecchymosis (bruising)
does not indicate a complication.
D. An apical pulse of 132 bpm with an irregular- irregular rhythm could indicate atrial fibrillation or
a rhythm with premature beats. Dysrhythmias are a complication that can occur following
coronary angiogram.

15. The client, returning from a coronary catheterization in which the femoral
artery approach was used, sneezes. Which should be the nurse’s priority
intervention?
A. Palpate pedal pulses
B. Measure vital signs
C. Assess for urticaria
D. Check the insertion site

ANSWER: D

A. Sneezing would not affect the pedal pulses.

B. Although the BP could decrease if the client were bleeding, this is not the priority.
C. Sneezing can be an early sign of an allergic reaction to the contrast but is a minor sign compared
to the potential loss of blood-
D. Checking the insertion site is priority. Sneezing increases intra-abdominal pressure and increases
the risk for clot disruption and bleeding from the femoral artery.
16 . The nurse obtains the client’s cardiac monitor print- out illustrated. What
should be the nurse’s interpretation of the client’s rhythm?

A. Atrial flutter
B. Atrial fibrillation
C. Sinus bradycardia
D. Sinus rhythm with premature atrial contractions (PACs)

ANSWER: C

A. Atrial flutter is either a regular or an irregular rhythm with multiple discernible P waves prior to
each QRS complex and no measurable PR interval.
B. Atrial fibrillation is an irregular rhythm with multiple nondiscernible fibrillatory P waves prior to
each QRS and no measurable PR interval.
C. Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 bpm and one
discernable P wave prior to each QRS.
D. Sinus rhythm with PACs is an irregular rhythm with a ventricular rate between 60 and 100 bpm,
one discemable P wave prior to each QRS, and a PR interval between 0.12 and 0.20 second, with
the presence of premature atrial beats that occur early in the cardiac cycle. The PACs also have
one discernible P wave prior to each QRS and a PR interval between 0.08 to 0.20 second.

17. The client with atrial flutter is receiving a continuous infusion of 25,000
units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a
PTT laboratory result is 92 seconds. According to the heparin infusion
protocol, the nurse shouldadminister the heparin infusion at a rate of how
many mL per hour?

__________ mL/hr (Record your answer as a whole number.)

ANSWER: 11

According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per
hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.

18. The nurse is admitting the client with a new diagnosis of persistent atrial
fibrillation with rapid ventricular response. The client has been in atrial
fibrillation for more than 2 days and has had no previous cardiac problems.
Which initial interventions should the nurse anticipate? Select all that apply.
A. Ablation of the AV node
B. Immediate cardioversion
C. Oxygen 2 liters per nasal cannula
D. Heparin intravenous (IV) infusion
E. Amiodarone IV infusion
F. Diltiazem IV infusion

ANSWER: C, D, E, F

A. Ablation of the AV node would only be considered if medications were ineffective in controlling
the client’s HR.
B. Cardioversion would only be considered if medications were ineffective in converting the client’s
rhythm and only after the presence of an atrial clot has been ruled out.
C. The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac
output. Administering oxygen enhances tissue oxygenation.
D. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent
thromboembolism.
E. Amiodarone (Cordarone) is used for pharma-cological cardioversion of the atrial fibrillation
rhythm.
F. Diltiazem (Cardizem), a calcium channel an- tagonist, is prescribed to slow the ventricular
response to atrial fibrillation. An alternative to a calcium channel antagonist would be the use of
a beta blocker, such as esmolol, metoprolol, or propranolol.
19. The nurse is caring for the client immediately following insertion of a
permanent pacemaker via the right subclavian vein approach. Which
intervention should the nurse include in the client’s plan of care to best
prevent pacemaker lead dislodgement?
A. Inspect the incision for approximation and bleeding
B. Prevent the right arm from going above shoulder level
C. Assist the client with using a walker when out of bed
D. Request a STAT chest x—ray upon return from the procedure

ANSWER: B

A. The dressing should not be removed to check the incision immediately after insertion but should
be checked for bleeding to monitor for potential complications.
B. Limiting arm and shoulder activity initially and up to 24 hours after the pacing leads are
implanted helps prevent lead dislodgement. Often an arm sling is used as a reminder to the
client to limit arm activity.
C. The nurse should assist the client the first time out of bed following a pacemaker implant, but
the client should not use a walker for 24 hours after the procedure, and out-of-bed activity
would not resume until the client is stable.
D. A postinsertion CXR is completed to check lead placement and to rule out a pneumothorax. It
does not promote the intactness of pacing leads.

20. The nurse completes teaching the client with a newly inserted ICD. Which
statement, if made by the client, indicates that further teaching is needed?
A. “The 1CD will give me a shock if my heart goes into ventricular fibrillation again.”
B. “When I feel the first shock, my family should start CPR immediately and call 911.”
C. “I’m afraid of my first shock; my friend stated his shock felt like a blow to the chest.”
D. “Some states do not allow driving until there is a 6-month discharge-free period.”

ANSWER: B

A. The ICD monitors the client’s heart rate and rhythm, identifies ventricular tachycardia or
ventricular fibrillation, and delivers a 25-joule or less shock if a lethal rhythm is detected.
B. CPR should only be initiated if the client is unresponsive and pulseless. EMS should be called if
there is more than one shock. This statement indicates further teaching is needed.
C. Various sensations have been described when the device delivers a shock, including a blow to or
kick in the chest.
D. State laws vary regarding drivers with ICDs. The decision regarding driving is also based on
whether dysrhythmias are present, the frequency of firing, and the client’s overall health.
21. The nurse is teaching the client newly diagnosed with chronic stable
angina. Which instructions on measures to prevent future angina should the
nurse incorporate? Select all that apply.
A. Increase isometric arm exercises to build endurance.
B. Wear a facemask when outdoors in cold weather.
C. Take nitroglycerin before a stressful event even if pain free.
D. Perform most exertional activities in the morning.
E. Take a daily laxative to avoid straining with bowel movements.
F. Discontinue use of all tobacco products if you use these.

ANSWER: B, C, F

A. Isometric exercise of the arms can cause exertional angina.

B. Blood vessels constrict in response to cold and increase the workload of the heart.
C. Nitroglycerin produces vasodilation and improves blood flow to the coronary arteries and
should be taken before exertional or stressful activities.
D. Exertional activity increases the HR, thus reducing the time the heart is in diastole, which is the
time when blood flow to the coronary arteries is the greatest. A period of rest should occur
between activities, and activities should be spaced.
E. Straining at stool increases sympathetic stimulation and cardiac workload, and it should be
avoided. However, a daily laxative should not be taken; it may result in diarrhea.
F. Nicotine stimulates catecholamine release, producing vasoconstriction and an increased HR.

22. The nurse collects the following assessment data on the client who has no
known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34
inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL
cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180
mg/dL. Which intervention should the nurse anticipate?
A. A low-calorie regular diet
B. A statin antilipidemic medication
C. A thiazide diuretic medication
D. Low-salt, low-saturated-fat, low-potassium diet

ANSWER: B

A. A low-calorie diet is not indicated. The normal BMI is 18.5 to 24.9.

B. A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will
lower the LDL cholesterol and triglyc erides and increase the HDL cholesterol.
C. The client’s BP is slightly elevated but would be initially treated with lifestyle changes, not a
diuretic.
D. While a low-saturated-fat diet is indicated, a low-potassium diet is not because the serum
potassium of 4.0 mEq/L is normal.
23. The nurse completes teaching the client about CAD and self-care at home.
The nurse determines that teaching is effective when the client makes which
statements? Select all that apply.
A. “If I have chest pain, I should contact my physician immediately.”
B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
E. “I plan to avoid being around people when they are smoking.”
F. “I plan on walking on most days of the week for at least 30 minutes.”

ANSWER: E, F

A. Medical attention is required only if pain persists, and then the client should call 911 rather than
the physician because emergency treatment may be necessary.
B. Nitroglycerin loses its potency if stored in warm, moist areas, making the client’s pants pocket
an undesirable location for storage.
C. Stopping activity decreases the body’s demand for oxygen. One nitroglycerin tablet should be
taken sublingually, not chewed. The nitroglycerin dilates coronary arteries and increases oxygen
to the myocardium. If pain is unrelieved, a second tablet should be taken 5 minutes later.
D. If pain is relieved after one tablet, another tablet is not required. The standard dose for
nitroglycerin is one tablet or spray 5 minutes apart until pain is relieved, to a maximum of three
tablets or sprays.
E. Passive smoke can cause vasoconstriction and decrease blood flow velocity even in healthy
young adults.
F. The American Heart Association recommends exercising for 30 minutes on most days of the
week.

24. The client calls for the nurse after experiencing sharp chest pains that
radiate to the left shoulder. All of the following interventions were prescribed
on admission for treating chest pain. Which intervention should the nurse
implement first?
A. STAT 12-lead electrocardiogram (ECG)
B. Oxygen 4 liters by nasal cannula
C. Nitroglycerin 0.4 mg sublingual
D. Morphine sulfate 2- 4 mg IV pm

ANSWER: B

A. Although a STAT 12-lead ECG is needed to identify ischemia or infarct location, the first action is
to treat the client’s pain.
B. Oxygen should be available in the room and should be initiated first to enhance oxygen flow to
the myocardium.
 C. Sublingual nitroglycerin dilates coronary arteries and will enhance blood flow to the
myocardium. Once oxygen is in place and the VS known, nitroglycerin should be administered.
D. Morphine sulfate is a narcotic analgesic used for pain control and anxiety reduction. Because it
is a controlled substance, extra steps are needed to retrieve the medication from a secure
source, so this is not the first action.

25. The nurse is assessing the client with an anterior-lateral MI. The nurse
should add decreased cardiac output to the client’s plan of care when which
finding is noted?
A. Pain radiates up left arm to neck
B. Presence of an S4 heart sound
C. Crackles auscultated in both lung bases
D. Vesicular breath sounds over lung lobes

ANSWER: C

A. Pain radiation is associated with an MI and does not necessarily indicate that output is
decreased.
B. An S4 heart sound is produced when blood flows forcefully from the atrium to a resistant
ventricle during late ventricular diastole.
C. An anterior-lateral MI can produce left ventricular dysfunction and low cardiac output. With
decreased cardiac output, blood accumulates in the heart and backs up into the pulmonary
system. The increased pulmonary pressure causes fluid to move into interstitial spaces and then
into the alveoli. The fluid will be auscultated as crackles in the lungs.
D. Vesicular breath sounds are normal over lesser bronchi, bronchioles, and lobes of the lung.

26 . The nurse increases activity for the client with an admitting diagnosis of
ACS. Which client finding best supports that the client is not tolerating the
activity?
A. Pulse rate increased by 15 beats per minute during activity
B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
C. Increased dyspnea and diaphoresis relieved when sitting in a chair
D. A mean arterial pressure (MAP) of 80 following activity

ANSWER: B

A. An increased HR during activity indicates the heart is able to adapt.

B. A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt
to the increased energy and oxygen demands of the activity. The client is not tolerating the
activity; the length of time or the intensity should be reduced.
C. The relief of dyspnea and diaphoresis with rest indicates the heart is able to adapt.
D. A MAP of 80 is normal.
27. The nurse is assessing the client following an inferiorseptal wall MI. Which
potential complication should the nurse further explore when noting that the
client has JVD and ascites?
A. Left-sided heart failure
B. Puhnonic valve malfunction
C. Right-sided heart failure
D. Ruptured septum

ANSWER: C

A. Left- sided HF produces signs of pulmonary congestion, including crackles, S3 and S4 heart
sounds, and pleural effusion.
B. A characteristic finding of pulmonic valve malfunction would be a murmur.
C. Right-sided HF produces venous congestion in the systemic circulation, resulting in JVD and
ascites (from vascular congestion in the GI tract). Additional signs include hepatomegaly,
splenomegaly, and peripheral edema.
D. A murmur would be auscultated with a ruptured septum, and the client would experience signs
of cardiogenic shock; these findings are not present.

28. The nurse is admitting the client experiencing dyspnea from HP and COPD
with high C02 levels. Which interventions should the nurse plan? Select all
that apply.
A. Apply oxygen 6 liters per nasal cannula.
B. Elevate the head of the bed 30 to 40 degrees.
C. Weigh daily in the am. after the client voids.
D. Teach client pursed-lip breathing techniques.
E. Turn and reposition the client every 1 to 2 hours.

ANSWER: B, C, D

A. Applying greater than 4 liters of oxygen per nasal cannula may be harmful. High flow rates can
depress the hypoxic drive. Because the client with COPD suffers from chronically high CO2
levels, the stimulus to breathe is the low 02 level (a hypoxic drive). A Venturi mask is a better
option.
B. Elevating the head of the bed will promote lung expansion.
C. Daily weights will assess fluid retention. Having the client void first provides for a more accurate
weight. Fluid volume excess can increase dyspnea and cause pulmonary edema.
D. Pursed-lip breathing techniques allow the client to conserve energy and slow the breathing rate.

29. The client with chronic HF tells the nurse, “I get so scared at night; I wake
up and feel like I can hardly breathe.” Which is the nurse’s best response?
 A. “You are experiencing a condition called paroxysmal nocturnal dyspnea.”
B. “Tell me if these are related to your having vivid nightmares?”
C. “You may be experiencing this from an increased sodium intake in your diet.”
D. “Tell me more about how often this is occurring and how you deal with it.”

ANSWER: D

A. Waking up at night with difficulty breathing describes paroxysmal nocturnal dyspnea, but the
nurse’s providing this information does not help the client to manage the nocturnal dyspnea.
B. The nurse is asking a closed-ended question, which does not help explore the entire issue, and
the client has not mentioned having nightmares.
C. The nurse is assuming that the client has increased sodium in the diet, which can cause excess
fluid to be retained, but this comment may make the client defensive.
D. When the client with HF expresses concerns about breathing, the nurse should further explore
the comment with an open-ended statement because more information may be gained about
how the client could diminish or handle the occurrence.

30. The client newly diagnosed with HF has an ejection fraction of 20%. Which
criteria should the nurse use to evaluate the client’s readiness for discharge
to home? Select all that apply.
A. There is a scale in the client’s home
B. The client started ambulating 24 hours ago
C. The client is receiving furosemide IV 20 mg bid
D. A smoking cessation consult is scheduled for 2 days after discharge
E. A home-care nurse is scheduled to see the client 3 days after discharge

ANSWER: A, B, E

A. A scale is needed to monitor a change in fluid status and weight gain.

B. The client should be ambulating 24 hours preceding discharge to determine functional
capability.
C. Oral diuretic agents such as furosemide (Lasix) should be administered 24 hours prior to
discharge to monitor effectiveness.
D. Smoking cessation should be initiated prior to, not after, discharge.
E. The client should have the home-care nurse visit or provide telephonic assistance within the first
three days of discharge.

31. The nurse observes that the client, 3 days post MI, seems unusually
fatigued. Upon assessment, the client is dyspneic with activity, has sinus
tachycardia, and has generalized edema. Which action by the nurse is most
appropriate?
 A. Administer high-flow oxygen.
B. Encourage the client to rest more.
C. Continue to monitor the client’s heart rhythm.
D. Compare the client’s admission and current weight.

ANSWER: D

A. There is no indication that the client is hypoxic and in need of high-flow oxygen. To treat the
dyspnea, oxygen by nasal cannula would be appropriate.
B. The fatigue is caused by decreased cardiac output, impaired perfusion to vital organs, decreased
tissue oxygenation, and anemia. Rest alone will not relieve the fatigue. Interventions are needed
to improve cardiac output and tissue oxygenation.
C. Continuing to monitor the client’s heart rhythm, without further assessment, will delay an
appropriate intervention.
D. A complication of MI is HF. Signs of HF include fatigue, dyspnea, tachycardia, edema, and weight
gain. Other signs include nocturia, skin changes, behavioral changes, and chest pain.

32. The client is hospitalized for HF secondary to alcohol-induced

cardiomyopathy. The client is started on milrinone and placed on a transplant
waiting list. The client has been curt and verbally aggressive in expressing
dissatisfaction with the medications, overall care, and the need for energy
conservation. Which nursing interpretation of the client’s behavior is most
appropriate?
A. The client is denying the illness.
B. The client is experiencing fear.
C. Alcohol abuse is affecting behavior.
D. A reaction to milrinone is affecting behavior.

ANSWER: B

A. There is no supporting evidence that the client denies the existence of a health problem.
Minimizing symptoms or noncompliant behaviors would indicate denial.
B. A threatening situation (need for heart trans- plant) can produce fear. Fear and helplessness
may cause the client to verbally attack health team members to maintain control.
C. Although alcohol abuse may affect neurological function, there is insufficient evidence in this
situation to support the conclusion that the alcohol is causing the client’s behavior.
D. Milrinone (Primacor) is used in short-term treatment of HF unresponsive to conventional
therapy with digoxin, diuretics, and vasodilators. It increases myocardial contractility and
decreases preload and after load by direct dilating effect on the vascular smooth muscle. It does
not cause behavior changes.
33. The nurse plans teaching for a 20-year-old newly diagnosed with
hypertrophic cardiomyopathy. The client is on the college soccer team. Which
infonnation should be the nurse’s priority when teaching the client?
A. Provide pamphlets on genetic testing to avoid passing on an inherited disease.
B. Reinforce the need to continue exercise with soccer to strengthen the heart.
C. Provide information about CPR to persons living with the client.
D. Counsel on foods for consuming on a low-fat, low-cholesterol diet.

ANSWER: C

A. Only half of the clients with hypertrophic cardiornyopathy have this autosornal dominant
disorder. Genetic testing may be important to include but is not a priority over the lifesaving
measures of CPR.
B. Strenuous exercise is restricted in clients with hypertrophic cardiomyopathy.
C. Because sudden cardiac death is a large risk factor for those under 30 years of age, the nurse
should provide information about having others living with the client trained in CPR as a
preventative measure.
D. Although consuming a low-fat, low-cholesterol diet is a good lifestyle choice, no specific diet will
prevent or reverse symptoms of hypertrophic cardiomyopathy.

34. The client with class II HF according to the New York Heart Association
Functional Classification has been taught about the initial treatment plan for
this disease. The nurse determines that the client needs additional teaching if
the client states that the treatment plan includes which component?
A. Diuretics
B. A low-sodium diet
C. Home oxygen therapy
D. Angiotensin-converting enzyme (ACE) inhibitors

ANSWER: C

A. Diuretics mobilize edematous fluid, act on the kidneys to promote excretion of sodium and
water, and reduce preload and pulmonary venous pressure.
B. Dietary restriction of sodium aids in reducing edema.
C. In class 11 HF, normal physical activity results in fatigue, dyspnea, palpitations, or angina] pain.
The symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other
comorbid conditions.
D. ACE inhibitors block the conversion of angiotensin l to the vasoconstrictor angiotensin II,
prevent the degradation of bradykinin and other vasodilatory prostaglandins, and increase
plasma renin levels and reduce aldosterone levels. The net result is systemic vasodilation,
reduced SVR, and improved cardiac output.
35. The client is admitted with acute infective endocarditis (IE). Which
assessment findings should the nurse associate with IE? Select all that apply.
A. Skin petechiae
B. Crackles in lung bases
C. Peripheral edema
D. Murmur
E. Arthralgia
F. Hemangioma

ANSWER: A, B, C, D, E

A. A vascular sign of microembolism is skin petechiae.

B. Crackles occur due to HF secondary to IE.
C. Peripheral edema occurs due to HF secondary to IE.
D. Vegetations that adhere to the heart valves can break off into the circulation, causing embolism,
valve incompetence, and a murmur.
E. Arthralgia (joint pain) can occur from microembolism and inadequate perfusion.
F. Hemangioma is a benign vascular tumor of dilated blood vessels; it is not associated with IE.

36 . The nurse is assessing the client following cardiac surgery. Which

assessment findings should be of the greatest concern to the nurse?
A. Jugular vein distention, muffled heart sounds, and BP 84/48
B. Temperature 96.4°F (358°C), heart rate 58 bpm, and shivering
C. Increased heart rate, audible SI and S2, and pain rated at a 5
D. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, and sinus rhythm with a few
PVCs

ANSWER: A

A. The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (Beck’s
Triad). This is a life-threatening event suggesting cardiac tamponade.
B. These are expected findings postsurgery, although efforts should be made to rewarm the client
and prevent shivering.
C. An increased HR can occur with a pain rated a 5; these are expected findings postsurgery.
D. The CVP, urine output measurement, and cardiac rhythm are within normal findings. A urine
output of 30 mL is the minimum hourly urine output. A urine output of less than 30 mL/hr is
indicative of decreased perfusion and needs further follow-up. If PVCs are frequent and cause
symptoms, follow-up is needed.
37. The nurse is giving discharge teaching to the client following aortic valve
replacement surgery with a synthetic valve. The nurse evaluates that the
client understands the teaching when the client states plans to take which
action? Select all that apply.
A. Use a soft toothbrush for dental hygiene.
B. Floss teeth daily to prevent plaque.
C. Wear loose-fitting T—shirts or tops.
D. Use an electric razor for shaving.
E. Consume foods high in vitamin K.

ANSWER: A, C, D

A. Using a soft toothbrush reduces the risk for bleeding when taking anticoagulants that are
prescribed when the client has a synthetic heart valve.
B. Flossing should be avoided because it causes tissue trauma, increases the risk of bleeding, and
increases the risk of infective endocarditis.
C. Loose-fitting clothing, such as T-shirts, will avoid friction on the sterna] incision.
D. An electric razor is safer than a straight-edge or disposable razor in preventing nicks or cuts
when shaving. The client will be on anti- coagulants that increase the risk for bleeding.
E. The diet should contain normal amounts of vitamin K; excessive amounts antagonize the effects
of the anticoagulant.

38. The male client states to the nurse, “I’ve recovered after having my new
artificial heart valve inserted. Now I want to have a vasectomy so I don’t get
my wife pregnant.” What is the nurse’s best response?
A. “That’s probably not a good idea. You could get an infection and damage the new valve.”
B. “You seem relieved that surgery was successful and that you can enjoy a normal life again.”
C. “Be sure to take a nitroglycerin tablet before sexual intercourse to prevent any chest pain.”
D. “Inform your surgeon about the new valve so antibiotics are prescribed before the procedure.”

ANSWER: D

A. A vasectomy is possible after a heart valve replacement, but prophylactic antibiotics are
prescribed before the procedure.
B. Although responding that the client seems relieved is a therapeutic response, it is not the best
response, because the client needs teaching.
C. Nitroglycerin is not prescribed for persons with valvular heart disease unless the person also has
CAD.
D. The surgeon should be aware of the artificial heart valve because antibiotics are required prior
to invasive procedures to prevent com- plications such as endocarditis. The client is also taking
an anticoagulant and would be at risk for bleeding.
39. The client who had a synthetic valve replacement a year ago is
hospitalized with unstable angina. IV heparin and nitroglycerin infusions
were started, but then nitroglycerin was discontinued alter the client’s pain
resolved. The HCP prescribes to start oral warfarin 5 mg at 1900 hours. Which
is the nurse’s best action?
A. Administer the warfarin as prescribed
B. Call the HCP to question starting warfarin
C. Discontinue heparin and then give warfarin
D. Hold warfarin until heparin is discontinued

ANSWER: A

A. Both heparin and warfarin (Coumadin) are anticoagulants, but their actions are different. Oral
warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still
on heparin. Warfarin should be given as prescribed.
B. Calling the HCP is unnecessary because warfarin is indicated with a synthetic valve replacement
and should be given as prescribed.
C. The nurse should not discontinue the heparin without its being prescribed.
D. The nurse should not hold the warfarin without its being prescribed to be held.

40. The client is scheduled for a coronary artery bypass graft in one week.
Which instructions should the nurse provide to the client? Select all that
apply.
A. Stop taking aspirin now and any products containing aspirin.
B. Do perform aerobic exercises 30 minutes daily before surgery.
C. Use the prescribed antimicrobial soap before hospital arrival.
D. Shave your chest and legs and then shower to remove the hair.
E. Resume normal activities when discharged from the hospital.

ANSWER: A, C

A. Aspirin decreases platelet aggregation and increases the risk of bleeding. It is usually
discontinued a week prior to surgery.
B. Aerobic exercises before surgery may be too strenuous and increase oxygen demand. A post-
operative cardiac rehabilitation program is begun usually on the second postoperative day and
includes exercises while being monitored.
C. The client should use an antimicrobial soap when showering or bathing as prescribed, usually a
day or two before and the day of surgery, to decrease the risk of infection.
D. Although the client’s skin will be shaved, this will be completed just prior to surgery to avoid
nicks and decrease the risk of infection.
E. Activities that stress the sternum, such as lifting, driving, and overhead reaching, will be
restricted after surgery.
41. The nurse is caring for the client following a coronary artery bypass graft.
Which assessment finding in the immediate postoperative period should be
most concerning to the nurse?
A. Copious chest tube output; now none for 1 hour
B. Current core temperature of 101.3°F (385°C)
C. pH 7.32; Paco2 48; HCO3 28; Pao2 80
D. Urine output 160 mL in the last 4 hours

ANSWER: A

A. A copiously draining chest tube that is no longer draining indicates an obstruction. It should be
most concerning because there is an increased risk for cardiac tamponade or pleural effusion.
B. A slight elevation in temperature could be the effect of rewarming or inflammation after
surgery. This should continue to be monitored but is not immediately concerning. Core
temperature is one degree higher than an oral temperature.
C. The ABG results show compensated respiratory acidosis. Although the pH is low and the PaCOg
is high, the kidneys are compensating by conserving HCO3. Normal pH is 7 .35—7 .45, PaCO2 is
32—42 mm Hg, HCO3 is 20—24 mmol/L, and Pa02 is 75—100 mm Hg.
D. A. urine output of 160 mL/4h is equivalent to 40 mL/h, which is adequate, but it warrants
continued monitoring. Less than 30 mL/h indicates decreased renal function.

42. The nurse fails to obtain scheduled VS at 0200 hours for the client who had
cardiac surgery 2 days ago. After assessing the client at 0600 hours, the nurse
documents the 0600 HR for both the 0200 and 0600 VS. Which conclusion
should a supervising charge nurse make about the nurse’s actions? Select all
that apply.
A. The nurse’s action was acceptable; neither complications nor harmful effects occurred.
B. The nurse’s action is concerning legally; the nurse fraudulently falsified documentation.
C. The nurse’s action demonstrates beneficence; the nurse decided what was best for the client.
D. The nurse’s action is extremely concerning; it involves the ethical issue of veracity.
E. The nurse’s action demonstrates distributive justice; other clients’ needs were priority.

ANSWER: B, D

A. Even if harm had not occurred, the nurse’s behavior of falsifying documentation poses an
ethicallegal concern and is never the correct action.
B. Documenting VS that the nurse did not obtain is a legal concern because documents were
falsified and the nurse was untruthful regarding obtaining the VS.
C. Beneficence is doing good. There is no information to indicate the nurse did what was best for
the client.
D. The nurse’s actions involve the ethical issue of veracity, or telling the truth. The nurse was
untruthful regarding obtaining the 0200 hour HR.
 E. Distributive justice is the distribution of resources to clients. There is no information about the
resources available to the nurse.

43. The nurse, assessing the client hospitalized following an M1, obtains these
VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned
that the client may be experiencing which most life-threatening complication?
A. Pulmonary embolism
B. Cardiac tamponade
C. Cardiomyopathy
D. Cardiogenic shock

ANSWER: D

A. Pulmonary embolism is a cause of cardiogenic shock and could occur after an MI, but it is not
the most life-threatening complication.
B. Cardiac tamponade is a cause of cardiogenic shock, but cardiac tamponade would not be
expected after an M1.
C. Cardiomyopathy may be an underlying cause of the MI, but it would not be an immediate
complication following an M1.
D. The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to
inadequate tissue perfusion and initiation of the shock syndrome).

44. The nurse, caring for the client following an anterior MI, obtains the
assessment findings illustrated- Based on these findings, the nurse should
immediately notify the HCP and plan which intervention?

A. Administer an IV fluid bolus of 0.9% NaCl; the client is in right heart failure-
B. Initiate an IV infusion of dopamine; the client is in cardiogenic shock.
 C. Prepare the client for pericardiocentesis; the findings support cardiac tamponade.
D. Notify radiology for a STAT chest x-ray to rule out pulmonary embolism (PE).

ANSWER: B

A. IV fluids may be administered if the client is showing signs of dehydration. However, the client is
not experiencing right-sided HF. Right HF produces signs of venous congestion, including jugular
venous distention, hepatomegaly, splenomegaly, and ascites.
B. Complications of an anterior MI are left ventricular failure, reduced cardiac output, and
cardiogenic shock. The client’s MAP is 55 (MAP = [Systolic BP + 2 Diastolic BP]/3 or 85 + 40 + 40 =
165/3 = 55). Hypotension, tachycardia, tachypnea, a low MAP, and decreasing urine output are
classic signs of cardiogenic shock. Dopamine (Intropin) is administered in cardiogenic shock to
increase cardiac output.
C. Although symptoms of cardiac tamponade do include hypotension, tachycardia, and tachypnea,
other signs include muffled heart sounds. Appropriate treatment for cardiac tamponade is
pericardiocentesis.
D. A CXR is used to diagnose PE, but the data do not suggest PB. The signs of PE can be subtle and
nonspecific but most commonly present with dyspnea, tachycardia, tachypnea, and/or chest
pain.

45. The cardiac monitor of the client diagnosed with Prinzmetal’s angina
shows a prolonged PR interval of 0.32 seconds- Which prescribed medication
should the nurse question administering to the client?
A. lsosorbide mononitrate 20 mg oral daily
B. Amlodipine 10 mg oral daily
C. Nitroglycerin 0.4 mg sublingual pm
D. Atenolol 50 mg oral daily

ANSWER: D

A. lsosorbide rnononitrate (,Imdur), a nitrate, causes vasodilatation of the large coronary arteries.
Nitrates act as an exogenous source of nitric oxide, which causes vascular smooth muscle
relaxation, resulting in decreased myocardial oxygen consumption and a possible modest effect
on platelet aggregation and thrombosis. It will not prolong the PR interval further.
B. Amlodipine (Norvase), a calcium channel bloclker, relaxes coronary smooth muscle and
produces coronary vasodilation. This in turn improves myocardial oxygen delivery. It will not
prolong the PR interval further.
C. Nitroglycerin (Nitrostat) sublingual effectively treats episodes of angina and myocardial ischemia
within minutes of administration. It will not prolong the PR interval further.
D. Atenolol (Tenormin), a beta blocker, blocks stimulation of betal (myocardial)-adrenergic
receptors, causing a reduction in BP and HR. A side effect of the medication is a prolongation of
the PR interval (normal PR interval is 0.12 to 0.20 second). Continued use of the drug can result
in heart block. The nurse should question administering atenolol.
46 . The nurse is to administer 40 mg of furosemide to the client in HP. The
prefilled syringe reads 100 mg/mL. In order to give the correct dose, how
many milliliters should the nurse administer to the client?

____________ mL. (Record your answer rounded to the nearest tenth.)

ANSWER: 0.4

Use a proportion formula and multiply the extremes (outside values) and the means (inside values);
then solve for X

100 mg: 1 mL :: 40 mg:XmL;100X=40;

X = 0.4

The nurse should administer 0.4 mL of furosemide (Lasix).

47. The nurse receives a serum laboratory report for six different clients with
admitting diagnoses of chest pain. Prioritize the order in which the nurse
should address each client’s laboratory result.
A. Troponin T 42 ng/mL (0.0-0.4 ng/mL)
B. WBC 11,000/mm3
C. Hgb 7.2 g/dL
D. SCr 2.2 mg/dL
E. K 2.2 mEq/L
F. Total cholesterol 430 mg/dL

ANSWER: A, E, C, D, F, B

A. Troponin T 42 ngImL (0.0 - 0.4 ng/mL). The nurse should address the elevated troponin level first.
Cardiospecific troponins (troponin T, cTnT, and troponin I, cTnI) are released into circulation after
myocardial injury and are highly specific indicators of MI. Since “time is muscle,” the HCP should be
notified and the client treated immediately to prevent extension of the infarct and possible death.

E. K 2.2 mEq/L. The nurse should address the decreased serum potassium level (K) second. The normal
serum K level is 3.5 to 5.8 mEq/L. A low serum level can cause life-threatening dysrhythmias.

C. Hgb 7.2 g/dL. The normal Hgb is 13.1 to 17.1 g/dL. A low Hgb can contribute to inadequate tissue
perfusion and contribute to myocardial ischemia.

D. SCr 2.2 mg/dL. The normal serum creatinine (SCr) is 0.4 to 1.4 mgldL. Impaired circulation may be
causing this alteration, and further client assessment is needed. Medication doses may need to be
adjusted with impaired renal perfusion.
F. Total cholesterol 430 mg/dL. The normal total serum cholesterol should be less than 200 mg/dL. This
is a risk factor for development of CAD. The client needs teaching.

B. WBC 11,000/mm3. The normal WBC count is 3900 to 11,900 cells/mm3. Because the finding is
normal, it can be addressed last.

48. After receiving normal CXR results of the client who had cardiac surgery,
the nurse proceeds to remove the client’s chest tubes as prescribed. Which
intervention should be the nurse’s priority?
A. Auscultate the client’s lung sounds
B. Administer 2 mg morphine sulfate intravenously
C. Turn off the suction to the chest drainage system
D. Prepare the dressing supplies at the client’s bedside

ANSWER: B

A. Auscultating the client’s lungs before and alter the procedure is necessary to ensure that an air
leak did not occur with removal, but administering the analgesic should be first.
B. Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered
first.
C. Turning off the suction is necessary, but administering the analgesic should be first.
D. Assembling the dressing supplies is necessary, but administering the analgesic should be first.

49. The nurse who is beginning a shift on a cardiac step-down unit receives
shift report for four clients. Prioritize the order, from most urgent to least
urgent, that the nurse should assess the clients.
A. The 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV)
heparin and has a partial thromboplastin time (PTT) due back in 30 minutes
B. The 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20
mL/hr urine output, and a “Do Not Resuscitate” order; whose family has just arrived
C. The 72-year~old client who was transferred 2 hours ago from the intensive care unit (ICU)
following a coronary artery bypass graft and has new-onset atrial fibrillation with rapid
ventricular response
D. The 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72
mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature
101.2°F (384°C)

ANSWER: C, D, A, B

C. The 72-year-old client who was transferred 2 hours ago from the ICU following a coronary artery
bypass graft and has new-onset atrial fibrillation with rapid ventricular response. This client should be
assessed first because the client is most unstable and the rhythm most life—threatening.
D. The 38-year—old postoperative client who had an aortic valve replacement 2 days ago, 31’ 114/72
mm Hg, HR 100 bpm, RR 28 breaths/min, and T 101.2°F (38.4°C). This postoperative client is assessed
next be- cause the elevated temperature, respiratory rate, and heart rate increase the demands on the
heart and could be a sign of pulmonary complications.

A. The 56-year-old client who was admitted 1 day ago with chest pain receiving IV heparin and has a PTT
due back in 30 minutes. The nurse should assess this client next. PTT results should be back, and the
dose may require adjustment.

B. The 62-year-old client with end-stage cardiomyopathy, BP of 78/50 mm Hg, 20 mL/hr urine output,
and a “Do N at Resuscitate” order; whose family has just arrived. This client can be assessed last. The
family members will have had time alone with the client, and the client and family may need emotional
support.

50. The RN and the NA are caring for four clients, all in need of immediate
attention. The NA is a senior nursing student who has been giving medications
and performing procedures on clients as a student nurse. The unit charge
nurse determines that care is appropriate when the RN working with the NA
delegates which actions? Select all that apply.
A. Give acetaminophen to the client with a high temperature.
B. Take vital signs on the client newly admitted with heart failure.
C. Discuss the pacemaker discharge handout so this client can go home.
D. Change this client’s chest tube dressing; it got wet with drinking water.
E. Provide a sponge bath for the client with the increased temperature.

ANSWER: B, E

A. Medication administration is not within the NA’s scope of practice.

B. The RN delegates appropriately when having the NA take the VS.
C. Teaching is not Within the NA’s scope of practice.
D. Performing a chest tube dressing change where there is the potential for introducing air during
the procedure is not Within the NA’s scope of practice.
E. The RN delegates appropriately when having the NA perform a sponge bath.

51. The nurse is assessing the client with an 8—centimeter AAA. Which
finding should the nurse expect?
A. Report of persistent nagging pain in the upper anterior chest
B. Systolic bruit palpated over the upper abdomen
C. Edema of the face and neck with distended neck veins
D. A pulsating mass in the mid to upper abdomen

ANSWER: D
 A. The client with an AAA typically reports persistent nagging pain in the abdomen, flank, and/or
back, not the anterior upper chest.
B. A systolic bruit (swishing-like sound) may be auscultated over the abdominal aneurysm; a bruit
is not palpated.
C. Edema of the face and neck with distended neck veins is associated with thoracic aortic
aneurysms, not AAA.
D. Throbbing or pulsating in the abdomen is the sign most indicative of an AAA.

52. The nurse is assessing the client who underwent repair of an aortic
aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate
the posterior tibial pulse of one leg that was palpable 15 minutes earlier.
What should be the nurse’s priority?
A. Recheck the pulse in 5 minutes.
B. Reposition the affected leg.
C. Notify the surgeon of the finding.
D. Document that the pulse is absent.

ANSWER: C

A. Rechecking the pulse in 5 minutes could allow ischemia to progress.

B. The leg should already be in an appropriate position, so repositioning is not indicated.
C. The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse
could signify graft occlusion or embolization.
D. Although the nurse should document the finding, this is not the priority.

53. While the nurse is assessing the client, the client says, “I had an
endovascular repair of an AAA that was found 1 month ago during a routine
physical.” The nurse’s assessment of the client should be based on
understanding that this procedure involves which action?
A. Excision to remove the aneurysm and place a graft percutaneously
B. An angioplasty with placement of a stent around the outside of the aorta
C. Placement of a filter within the aneurysm to block clots from becoming emboli
D. Placement of a stent graft inside the aorta that excludes the aneurysm from circulation

ANSWER: D

A. The aneurysm is left in place.

B. Angioplasty (ballooning of plaque from the inside) is not involved, and the stent is placed inside,
not outside, the aorta.
C. Filters are not involved.
D. The endovascular repair consists of placement of the endovascular stent graft inside the aorta,
extending above and below the aneurysmal area to seal it off from the circulation.
54. The client is discovered to have a popliteal aneurysm. Because of the
aneurysm, the nurse should closely monitor the client for which associated
problem?
A. Thoracic outlet syndrome
B. Ischemia in the lower limb
C. Puhnonary embolism
D. Raynaud’s phenomenon

ANSWER: B

A. Thoracic outlet syndrome is compression of the subclavian artery due to anatomic structures,
leading to pain and ischemia. in the arm.
B. A popliteal aneurysm (located in the space behind the knee) may cause ischemia in the leg distal
to the aneurysm due to thrombus forming inside the aneurysm and potential emboli.
C. Pulmonary embolism develops from deep venous thrombosis in the leg or pelvic veins.
D. Raynaud’s phenomenon consists of vasospasms in small arteries of the extremities, causing
intermittent ischemia.

55. The nurse is admitting the client with a thoracic aortic aneurysm. Which
intervention should the nurse plan to include?
A. Administering antihypertensive medications
B. Palpating the abdomen to determine the aneurysm’s size
C. Inserting a nasogastric tube set to moderate suction
D. Teaching about a diet high in potassium and low in sodium

ANSWER: A

A. The nurse should include administering anti- hypertensive medications to the client with a
thoracic aortic aneurysm; controlling HR and BP is important to decrease the risk of aneurysm
rupture.
B. The ribs would prevent palpation of the aneurysm; palpation of any aneurysm is contraindicated
due to the risk of plaque breaking loose or aneurysm rupture.
C. An NG tube is not indicated for this client with only the information presented.
D. There is no indication that the client should be receiving a high-potassium and low-sodium diet.

56 . The nurse is preparing the client for a thoracic aneurysm repair. Which
assessment findings should prompt the nurse to conclude that a rupture may
have occurred? Select all that apply.
A. Oliguria
B. Dyspnea
C. Hypotension
D. Abdominal distention
E. Severe chest pain radiating to the back
ANSWER: A, B, C, E

A. Blood loss will lead to low BP and scant urinary output due to decreased renal perfusion.
B. The pressure from the hemorrhage will interfere with the client’s breathing, causing dyspnea.
C. Blood loss will lead to low BP (hypotension).
D. A thoracic aneurysm does not cause abdominal distention because the bleeding is in the
thoracic area.
E. A thoracic aneurysm that ruptures will cause pain in the thoracic area.

57. Upon assessing the client who has distal foot pain due to vascular
insufficiency, the nurse notes the wound illustrated. When reviewing the
client’s medical record, which notation is the nurse likely to find?

A. Venous ulcer on left foot

B. Arterial ulcer on right foot
C. Diabetic ulcer on left foot
D. Stress ulcer on right foot

ANSWER: B

A. Venous ulcers typically occur at the ankle area with ankle discoloration; they have a pink ulcer
bed with granulation tissue and are typically superficial with uneven, undefined edges.
B. The nurse should find a notation of an arterial ulcer on the right foot. Arterial ulcers typically
occur on the feet; they are deep, and the ulcer bed is pale with even, defined edges and limited
granulation tissue.
C. Diabetic ulcers are typically seen on the plantar area of the foot and are painless; there is no
indication that this client has diabetes.
D. A stress ulcer occurs in the gastric mucosa and not on the lower extremities; a pressure ulcer
may be found on bony prominences.

58. The nurse is completing a home visit with the client who has an arterial
ulcer secondary to PAD. Which statement by the client warrants immediate
inter- vention by the nurse?
 A. “I soak my feet daily to warm them and keep them soft.”
B. “I cover the sore on my foot with sterile gauze to protect it.”
C. “I use a pillow under my calves to keep my heels off the bed.”
D. “I lubricate my feet daily to prevent them from cracking.”

ANSWER: A

A. The nurse should immediately intervene when the client states soaking feet daily; foot soaks
when the client has PAD can cause maceration (tissue breakdown).
B. Covering a sore with sterile gauze is an appropriate action for the client with a peripheral ulcer
from PAD and does not require that the nurse intervene.
C. Using a pillow under the knees will keep the heels from having pressure areas; it is an
appropriate action for the client with PAD and does not require that the nurse intervene.
D. Daily foot lubrication prevents cracking and infection and is an appropriate action for the client
with PAD and does not require that the nurse intervene.

59. Two days ago the client underwent femoral popliteal artery bypass graft
surgery. What should be the nurse’s priority at this time?
A. Monitor intake and output every four hours.
B. Report any edema that develops in the operative leg.
C. Place the client in a 60-degree sitting position when in bed.
D. Check pedal and post tibial pulses bilaterally every 4 hours.

ANSWER: D

A. I & O is important to monitor for fluid retention, dehydration, or renal function, but is not the
priority.
B. Edema in the operative leg is expected from the surgical procedure and improved circulation.
C. Bending from the hip or knee should be limited to avoid graft occlusion.
D. The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion.
Checking both sides allows for comparison.

60. The nurse reviews symptoms of acute graft occlusion with the client who
has had a revascularization graft procedure of the lower extremity. Which
symptom of acute arterial occlusion stated by the client indicates the need for
further teaching?
A. Severe pain
B. Paresthesia
C. Warm and red incisions
D. Inability to move the foot

ANSWER: C
 A. Lack of blood supply to a body extremity may result in pain, pallor, pulselessness, paresthesia
(numbness and tingling), paresis (decreased ability to move), and poikilothennia (coolness).
B. Lack of blood supply to a body extremity may result in paresthesia (numbness and tingling).
C. Redness and warmth along the incision line are associated with inflammation or infection, not
graft occlusion.
D. Lack of blood supply to a body extremity may result in paresis (weakness) or paralysis (inability
to move the foot).

61. The client with symptoms of intermittent claudication receives treatment

with a peripheral percutancous transluminal angioplasty procedure with
placement of an endovascular stent. Which statements, if made by the client,
support the home-care nurse’s conclusion that the client is making lifestyle
changes to decrease the likelihood of restenosis and arterial occlusion? Select
all that apply.
A. “I have been doing exercises twice daily.”
B. “All nicotine products were thrown away.”
C. “These support hose keep my legs warm.”
D. “I see a podiatrist tomorrow for foot care.”
E. “I'm following a low-saturatcd-fat diet”
F. “I now take rosuvastatin calcium.”

ANSWER: A, B, E, F

A. Exercising promotes collateral circulation.

B. Discontinuing the use of nicotine products deters the arteriosclerotie process.
C. Wearing support hose may impede circulation and increase the risk of restenosis.
D. Receiving professional foot care is a positive factor but does not prevent the progressive nature
of peripheral arterial disease.
E. A low-saturated-fat diet deters the arteriosclerotie process.
F. Taking cholesterol-lowering medications such as rosuvastatin calcium (Crestor) deters the
arteriosclerotie process.

52. The client who has pain while walking has an ankle-brachial index (ABI)
test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on
these results, which should be the nurse’s conclusion?
A. The client likely has peripheral arterial disease (PAD).
B. Ticlopidinc hydrochloride should be prescribed.
C. The client’s pain is most likely psychological in origin.
D. Medical follow-up is needed to determine the cause of pain.

ANSWER: D
 A. Based on the results of the ABI, the client has normal arterial circulation. A ratio of less than 0.9
is diagnostic of PAD.
B. The client would not benefit from ticlopidine hydrochloride (Ticlid); the client has normal
arterial circulation.
C. There is no information relating the pain to a psychological concern.
D. The client requires further medical consultation because the ABI (comparison of BP in ankle to
the brachial BP) is normal in each leg.

63. The nurse assesses the client at a vascular clinic after being treated with
pentoxifyllinc for 6 weeks. The nurse determines that pentoxifylline has been
effective when noting that the client has which finding?
A. A decrease in lower-extremity edema
B. No symptoms of withdrawal after quitting smoking
C. A venous ulcer on the ankle that has decreased in size
D. The ability to walk a longer distance without claudication

ANSWER: D

A. A diuretic medication is used to decrease edema.

B. Pentoxifylline is not prescribed for smoking cessation. Nicotine substitutes are commonly
prescribed to control nicotine withdrawal symptoms.
C. Venous ulcers resulting from prolonged venous hypertension are not treated with pentoxifylline.
D. Pentoxifylline (Trental) is thought to act by improving capillary blood flow and is prescribed to
decrease intermittent claudication. Effects are usually seen in 2 to 4 weeks.

64. The client, who is a lS-pack—year cigarette smoker, has painful fingers and
toes and is diagnosed with Buerger’s disease (thromboangiitis obliterans).
Which measure to prevent disease progression should be the nurse’s initial
focus when teaching the client?
A. Avoid exposure to cold temperatures
B. Maintain meticulous hygiene
C. Abstain from all tobacco products
D. Follow a low-saturated-fat diet

ANSWER: C

A. Avoiding exposure to cold will reduce the pain but is not the nurse’s initial focus.
B. Maintaining meticulous hygiene is a positive action to follow but is not the nurse’s initial focus.
C. Buerger’s disease is an uncommon vascular occlusive disease that affects the medial and small
arteries and veins, initially in the distal limbs. It is strongly associated with tobacco use, which
causes vasoconstriction. The most important action to communicate to the client is that he must
abstain from tobacco in all forms to prevent progression of the disease.
D. A low-saturated-fat diet is a healthy diet but is not the nurse’s initial focus.
65. The client with Raynaud’s disease is seen in a vascular clinic 6 weeks after
nifedipine has been prescribed. The nurse evaluates that the medication has
been effective when which findings are noted?
A. The client’s blood pressure is 110/68 mm Hg.
B. The client states experiencing less pain and numbness.
C. The client states that tolerance to heat is improved.
D. The client walks without intermittent claudication

ANSWER: B

A. Nifedipine is used as an antihypertensive agent, but that is not the purpose with Raynaud’s
disease. The client is at risk to develop hypotension as an adverse effect.
B. Raynaud’s disease is a disease in which cutaneous arteries in the extremities have recurrent
episodes of vasospasm that result in pain and numbness. Nifedipine (Procardia), a calcium-
channel blocker, causes vasodilation, thus reducing pain and numbness.
C. Tolerance to cold, not heat, should improve.
D. Claudication is not associated with Raynaud’s disease but is associated with arteriosclerotie
changes in the larger arteries.

66 . The client is prescribed to have an elastic bandage applied to the lower

extremity to reduce edema. At which position on the client’s leg should the
nurse start wrapping the elastic bandage?

A. Location A
B. Location B
C. Location C
D. Location D

ANSWER: D
 A. Applying the bandage starting at the knee will decrease venous return and increase edema in
the lower extremity.
B. Applying the bandage starting at the calf will decrease venous return and increase edema in the
lower extremity.
C. Applying the bandage starting at the ankle will decrease venous return and increase edema in
the foot.
D. The nurse should begin to apply the bandage at the distal point and proceed proximally. By
starting at this point, trapping fluid atop the foot is avoided. The purpose of the bandage is to
apply compression evenly to the lower leg.

67. The nurse is discussing healthy lifestyle practices with the client who has
chronic venous insufficiency. Which practices should be emphasized with this
client? Select all that apply.
A. Avoid eating an excess of dark green vegetables.
B. Take rests and elevate the legs while sitting.
C. Wear graduated compression stockings, removing them at night.
D. Increase standing time and shift weight when upright.
E. Sleep with legs elevated above the level of the heart.

ANSWER: B. C. E

A. Eating excessive amounts of dark green vegetables could affect the anticoagulant effect of
warfarin, but there is no indication the client is taking an anticoagulant.
B. Elevating the legs when sitting promotes venous return and reduces edema.
C. Wearing graduated compression stockings promotes venous return and reduces edema.
D. Clients who have chronic venous insufficiency should avoid prolonged standing.
E. Elevating the legs when sleeping increases venous return and reduces edema.

68. The client states to the clinic nurse, “I had pain in the left calf for a few
days earlier in the week, but I am pain free now.” The nurse’s assessment
findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion
bilaterally, a few visible varicose veins in each leg, and slight swelling in only
the left leg. Which is the nurse’s best action?
A. Ask if the client has been walking more lately.
B. Inform the HCP of the assessment findings.
C. Ask if the client has considered taking a baby aspirin daily.
D. Explain to the client that there are no significant findings.

ANSWER: B
 A. With the unilateral leg swelling, the nurse does not need additional assessment data about
activity.
B. The nurse should inform the HCP about the assessment findings. A possible DVT is taken
seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT.
C. Advising aspirin is not within the scope of nursing practice and has possible negative
consequences.
D. Findings are significant and should be reported to the HCP.

69. The nurse is caring for the client with varicose veins. Which action should
indicate to the nurse that an expected outcome has been met?
A. States will walk daily to promote venous return
B. Reports decreased need for compression stockings
C. States can finally stand for prolonged periods of time
D. Chooses diet high in potassium and low in magnesium

ANSWER: A

A. Walking promotes venous return; verbalizing intent to increase activity indicates an expected
outcome has been met for the client with varicose veins.
B. Compression stockings should be worn often to promote venous return and prevent further
varicosities, rather than decreasing their use.
C. Standing for a prolonged period of time should be avoided.
D. Choosing a diet high in potassium and low in magnesium does not apply to the client with
varicose veins.

70. The nurse is caring for multiple clients. Which client should the nurse
identify as having the greatest risk for developing a DVT?
A. The client with an area of slight intimation at the peripheral IV site with a PT of 25 seconds, INR
of 2.5.
B. The client postoperative hip arthroplasty who has venous insufficiency and is immobile; platelet
count = 550,000/mm3.
C. The client with a history of DVT admitted with chest pain and has a continuous intravenous
heparin drip; PTT of 55 seconds.
D. The client with dependent rubor, pallor upon lower-extremity elevation, and absent peripheral
pulses; platelet count of 350,000/mm3.

ANSWER: B

A. A PT of 25 seconds and INR of 2.5 are pro- longed and do not indicate hypercoagulability.
B. Blood stasis (immobility), endothelial injury (postoperative client), and hypercoagulability
(platelet count increased) suggest Virchow’s triad, which is associated with an increased risk of
DVT.
C. The client’s PTT of 55 seconds is prolonged and does not indicate hypercoagulability.
 D. This client has arterial insufficiency, not a venous disorder; the platelet count of 350,000/nnn3 is
Within the normal range.

71. The nurse is caring for the client with a suspected DVT. For which
diagnostic test should the nurse anticipate the client will need to be prepared?
A. V/Q Scan
B. Arteriogram
C. Venogram
D. Embolectomy

ANSWER: C

A. A V/Q scan is a venfilation/perfiision test that does not apply to this client. It may be performed
if the client has a pulmonary embolism.
B. An arteriogram allows visualization of arteries, not veins.
C. The nurse should anticipate preparing the client for a venogram, which allows visualization of
veins and is used to diagnose a DVT.
D. An embolectomy is the surgical removal of a clot, not a diagnostic study.

72. The nurse is caring for the client who had a cardiac valve replacement. To
decrease the risk of DVT and PE, which interventions should the nurse plan to
include? Select all that apply.
A. Apply a pneumatic compression device.
B. Administer a heparin infusion intravenously.
C. Encourage coughing and deep breathing hourly.
D. Teach about performing isometric leg exercises.
E. Avoid the use of graded compression elastic stockings.

ANSWER: A, D

A. A pneumatic compression device applies pulsing pressures similar to those that occur during
normal walking. They can help reduce the risk of DVT and PE.
B. Although giving heparin intravenously will achieve anticoagulation, a subcutaneous injection of
low-dose unfractionated or low-molecular- weight heparin is usually prescribed.
C. Coughing and deep breathing promote lung expansion and help prevent pulmonary
complications after surgery, but this does not decrease the risk for DVT or PE.
D. Isometric exercises are muscle-strengthening exercises that also compress vessels and thus
decrease the risk for DVT and PE.
E. Graded compression elastic stockings should be worn to improve venous return and prevent
thrombi formation. Their use is avoided if peripheral arterial disease is present.
73. The client returns to a hospital unit after undergoing placement of a vena
cava filter. Which intervention should the nurse implement?
A. Restart heparin therapy as soon as possible.
B. Reinforce the abdominal incision dressing.
C. Inspect the groin insertion site for bleeding.
D. Increase fluids to promote excretion of the dye.

ANSWER: C

A. Anticoagulation is not necessary if a vena cava filter is in place.

B. There is no abdominal incision with the percutaneous approach.
C. The procedure for placement of a vena cava filter is done percutaneously, usually through the
subclavian or femoral vein approach. The nurse should check the groin insertion site for
bleeding.
D. Dye is not used during placement of a vena cava filter.

74. The client reports pain, tenderness, and redness along the path of an arm
vein where potassium chloride (KCL) is infusing IV. Which interventions
should the nurse include when responding to this situation?
A. Call the HCP immediately; administer diphenhydramine.
B. Stop the infusion; apply a warm, moist compress to the affected area.
C. Slow the infusion rate; teach that IV potassium is usually uncomfortable.
D. Discontinue the potassium chloride; document the client’s allergic reaction.

ANSWER: B

A. Phlebitis does not warrant HCP notification; an antihistamine such as diphenhydramine

(Benadryl) is used to treat an allergic reaction, which this is not.
B. The nurse should immediately stop the KCL infusion; signs and symptoms indicate vein
inflammation, or phlebitis. After discontinuing the IV catheter, the nurse should apply a warm,
moist compress and restart the IV at another location, giving the infusion at a slower rate. If
facility policy allows, lidocaine should be added to the KCL infusion to decrease pain.
C. The infusion should be stopped, not slowed, because the vein is inflamed. Teaching is
appropriate that KCL given IV is commonly uncomfortable, but measures should be taken to
decrease the client’s discomfort, such as adding lidocaine to the solution or applying warm
compresses during administration.
D. Discontinuing the infusion entirely is inappropriate. An allergy should not be documented
because signs and symptoms do not indicate an allergy to KCL.

75. The client asks the nurse what can be done to alleviate the pain and
discomfort associated with varicose veins. Which response by the nurse is
best?
 A. “Dangle your legs off the side of the bed as often as possible to alleviate the pain.”
B. “There isn’t much you can do about the pain except have surgery to remove the veins.”
C. “You should wear long pants to hide bulging veins; this will help your self-confidence.”
D. “Wear elastic stockings to promote venous return; these will also help reduce discomfort.”

ANSWER: D

A. Dangling legs in a dependent position decreases venous return and will increase pain and
discomfort.
B. There are nonsurgical management options for treating varicose veins.
C. Telling the client to wear long pants implies judgment of the client’s perception of the varicose
veins; it also does not address the question of pain and discomfort associated with varicose
veins.
D. The best response to alleviate pain and discomfort associated with varicose veins includes
application of elastic stockings and elevating the lower extremities. These promote venous
return.