QUESTION PRACTICE

Cardiovascular system
DINESH RAJ
QUESTION PRACTICE
Q. Which modification used by the nurse is most
appropriate when taking the blood pressure of a
client who weighs250 pounds?
1. The nurse takes the blood pressure on the
client’s Thigh
2. The nurse has the client lie down during the
assessment.
3. The nurse pumps the manometer up to 250 mm
Hg.
4. The nurse uses an extra-large blood pressure
cuff.
4
The nurse can assume that an obese client will need an extra-
large adult cuff. A common guide is to select a cuff with a
bladder that encircles at least twothirds of the limb at its
midpoint and is as wide as 40% of the midlimb
circumference. If the cuff is too narrow, the blood pressure
will be higher than its true measurement; if too wide, the
measurement will be lower than the true pressure. A
normal-sized cuff will not fi t around the obese client’s
thigh. Having the client lie down would have no bearing on
the cuff size, but it could affect a client’s blood pressure
measurement; in this case, the cuff is too small anyway.
Pumping the manometer to 250 mm Hg is also incorrect.
The blood pressure manometer should be pumped up to
approximately 30 mm Hg above the baseline blood
pressure. The American Heart Association recommends the
following: Infl ate the cuff while palpating the brachial
artery, note when the pulse disappears, defl ate the cuff,
wait, and reinfl ate the cuff to 30 mm Hg above the point at
which the pulse disappeared.
QUESTION PRACTICE
Q. Which of the following client risk factors is most
signifi cant for developing CAD?
1. Drinking a nightly cocktail
2. History of mitral valve repair
3. Rheumatic fever during childhood
4. Weighing 25 pounds (11.3 kg) above norm
4
 4. Obesity, which is often linked with
hyperlipidemia, is a risk factor for developing
coronary artery disease (CAD). Drinking a
nightly cocktail and undergoing surgery to repair
the mitral valve are unrelated to development of
CAD. Rheumatic fever is more likely to cause
valvular disease than CAD.
QUESTION PRACTICE
Q. When the client asks the nurse how cholesterol
acts as a cardiac risk factor, what is the best
explanation?
1. Excess fat in the blood expands the circulating
blood volume.
2. Excess fat in the blood thickens the lining of the
arteries.
3. Excess fat in the blood causes slower blood
clotting.
4. Excess fat in the blood stimulates the heart to
beat faster
2
A buildup of cholesterol in the blood vessels causes a
condition known as atherosclerosis. As fat becomes
deposited within the lining of arteries, the depositsen
large to form plaque, which thickens the arterial
walls and causes the blood vessels to narrow.
Eventually the plaque is infiltrated with calcium,
which causes the vessel to become hard and rigid.
When a normal volume of blood is forced through
these narrowed, inelastic vessels, the press ure within
the vessels increases. Theheart is prone to failure
because it must work hard to pump against the
vascular resistance. Cholesterol neither expands the c
irculating blood volume nor causes the heart to beat
faster. Blood clots may form quicker due to the
narrowing blood vessel. This narrowing can also
cause stagnation of the blood
QUESTION PRACTICE
Q. After providing Atorvastatin instructions, the
best evidence that the client knows this drug’s
potential side effects is when the client states it
may cause which adverse effect?
1. Muscle pain
2. Palpitations
3. Visual changes
4. Weight loss
1
Atorvastatin (Lipitor), one of many drugs that are
referred to as statins, lowers low-density lipoprotein
and total triglyceride levels and increases the amount
of highdensity lipoproteins. In doses large enough to
lower blood fat components, this drug may cause back
pain and muscle pain (myalgia). Although the link
between statin drugs and myalgia as well as other
muscle pathology continues to be speculative, some
believe the side effect is due to a disruption in the
lipid membrane layer of muscle cells caused by a
depletion of cholesterol. The nurse must assess for
muscle pain, tenderness, or weakness along with
monitoring the client’s cholesterol levels. Palpitations,
visual changes, and weight loss are not known side
effects of this drug
QUESTION PRACTICE
Q. The nurse informs the client that the correct
way to administer nitroglycerin is to place one
tablet where?
1. Between the gum and cheek
2. At the back of the throat
3. Under the tongue
4. Between the teeth
QUESTION PRACTICE
Q. Which side effects are most closely associated
with the use of nitroglycerin tablets? Select all
that apply.
1. Headache
2. Backache
3. Diarrhea
4. Jaundice
5. Dizziness
6. Pallor
1,5
Side effects of nitroglycerin include headache, fl
ushing, hypotension and dizziness. These effects
are the direct result of vasodilation. The other
choices are not associated with nitroglycerin
QUESTION PRACTICE
Q. If the chest pain is not relieved after taking one
nitroglycerin tablet, the nurse should teach the
client to take what action?
1. Take another tablet in 5 minutes.
2. Drive to the emergency department.
3. Call the physician immediately.
4. Swallow two additional tablets
QUESTION PRACTICE
Q. Which assessment finding should signal the
nurse to withhold applying the client’s
nitroglycerin patch and notify the physician?
1. Temperature of 99.8°F (37.6°C)
2. Respiratory rate of 24 breaths/minute at rest
3. Apical heart rate of 90 beats/minute
4. Blood pressure of 94/62 mm Hg
QUESTION PRACTICE
Which statement by the client indicates an
understanding of what will happen during the
testing procedure?
1. “I will be able to hear my heart beating in my
chest.”
2. “I will feel a heavy sensation all over my body.”
3. “I will be anesthetized and will not feel any
discomfort.”
4. “I will feel a warm sensation as the dye is
instilled.”
4
The contrast dye used during the coronary
arteriogram causes vasodilation and is
experienced as a brief flush or warmth that
spreads over the skin surface. Some clients feel fl
uttering or what is described as “butterflies” as
the catheter is passed into the heart, disturbing
its rhythm. Heaviness or chest pain, if
experienced, is generally treated with
nitroglycerin. The client receives sedation but is
not anesthetized before the diagnostic testing.
QUESTION PRACTICE
Q. Before the cardiac catheterization and coronary
arteriogram, it is essential for the nurse to ask
the client about any allergy to iodine or which
other substance?
1. Penicillin
2. Morphine
3. Shellfi sh
4. Eggs
3
People who are allergic to shellfi sh may also be
sensitive to iodine. The radiopaque dye used
during the arteriogram is iodine based. The
physician must be notified if the client indicates
a history of allergies to either substance. At this
point, the physician will determine whether to
cancel the procedure or prepare to administer an
antihistamine or other emergency drugs.
Morphine and penicillin are not associated with
allergic reactions caused by the dye. Allergy to
eggs is related to certain types of vaccines given
as immunizations
QUESTION PRACTICE
Q. The nurse knows that the client understands
the physician’s explanation of the PTCA
procedure when the client makes which
statement?
1. “A balloon-tipped catheter will be inserted into
my coronary artery.”
2. “A Teflon graft will be used to replace an area of
weakened heart muscle.”
3. “A section of my leg vein will be grafted around
a narrowed coronary artery.”
4. “A battery-operated pacemaker will be
implanted to maintain my heart rate.”
1
 Percutaneous transluminal coronary angioplasty
(PTCA) involves dilating narrowed or occluded
coronary arteries with a double-lumen balloon
catheter. The pressure from the infl ated balloon
compresses the fatty plaque that has narrowed
the artery. Leg veins are used in coronary artery
bypass grafting (CABG) surgery to bypass
narrowed coronary arteries. A pacemaker is used
when its difficult to maintain a normal heart rate
or rhythm with drug therapy. Grafting skeletal
muscle, not Teflon, over scarred areas of the
myocardium is now in experimental stages.
QUESTION PRACTICE
Q. When the client asks the nurse how propranolol
helps to prevent angina, what is the best
explanation?
1. Propranolol promotes excretion of body fl uid.
2. Propranolol reduces the rate of heart
contraction.
3. Propranolol alters pain receptors in the heart.
4. Propranolol dilates the major coronary arteries
2
Propranolol (Inderal) is a beta-adrenergic blocker
(beta blocker). It blocks the sympathetic receptors for
epinephrine. Epinephrine speeds the heart rate,
which requires a great deal of oxygen. By blocking the
effect of epinephrine, the heart rate is slowed and the
myocardium does not need as much oxygen. In
addition, at a slower rate, the heart fi lls with a
greater volume of blood. Thus, each time the heart
contracts, it delivers a substantial amount of blood to
the coronary arteries. As long as the coronary arteries
deliver an adequate amount of oxygenated blood to
the myocardium, chest pain is prevented. Propranolol
(Inderal) does not dilate major coronary arteries, nor
does it help with the excretion of urine. Pain receptors
are not altered by the use of this drug.
QUESTION PRACTICE
Q. When the client returns to the room after the
percutaneous transluminal coronary angioplasty
(PTCA) procedure, which assessment finding
should be reported immediately to the physician?
1. Urine output of 100 mL/hour
2. Blood pressure of 108/68 mm Hg
3. Dry mouth
4. Chest pain
4
Despite dilating one or more coronary arteries with a balloon-
tipped catheter, it is possible for clients to experience chest
pain after percutaneous transluminal coronary angioplasty
(PTCA). Chest pain after PTCA should never be ignored or
dismissed as being inconsequential. It can occur for a variety
of reasons: sudden collapse of a previously dilated coronary
artery, thrombus formation within a coronary artery, or a
change in the diameter of an arterial lumen due to the
presence of a stent, for example. Whatever the reason, chest
pain should be reported immediately to the physician because
it may indicate a life-threatening complication. If a thrombus
in a coronary artery is untreated, a myocardial infarction (MI)
could occur. An hourly urine output of 30 to 50 mL or more is
considered adequate. A blood pressure of 108/68 mm Hg is
within the low ranges of normal. A dry mouth is a
consequenceof fl uid restriction and medication administered
before the procedure. As long as the bloodpressure continues
to remain within normal ranges, the nurse relieves the
discomfort of a dry mouth by giving oral care and administering
oral fl uids
QUESTION PRACTICE
Q. The nurse checking the client’s leg incision is
aware that which is the most common blood
vessel used in CABG surgery?
1. The saphenous vein
2. The femoral artery
3. The popliteal vein
4. The iliac artery
QUESTION PRACTICE
Q. After the coronary artery bypass graft (CABG)
surgery, which assessment finding provides the
best evidence that collateral circulation at the
donor graft site is adequate?
1. The client is free from chest pain.
2. The client’s toes are warm and non edematous.
3. The client moves the operative leg easily
2
The saphenous vein is the most common blood vessel
used for coronary artery bypass graft (CABG) surgery.
Removing a portion of this leg vein can temporarily
impair the return of venous blood to the heart.
Impaired venous return is manifested by cool skin
and edema in the toes, foot, or ankle of the operative
leg. Therefore, the fact that the toes are warm and
nonedematous is the best evidence that venous blood
is adequately returning to the heart through other
blood vessels in the leg. The ability to move the leg
indicates that neurologic function is intact. A regular
heart rate and absence of chest pain are evidence that
the newly attached graft is supplying the heart
muscle with adequate oxygenated blood.
QUESTION PRACTICE
Q. Which assessment finding is most closely
correlated with an evolving MI?
1. Profuse sweating
2. Facial flushing
3. Severe headache
4. Coughing up pink-tinged mucus
QUESTION PRACTICE
Q. Because the client is exhibiting signs and
symptoms of congestive heart failure (CHF),
which position suggested by the nurse is most
beneficial for the client at this time?
1. Supine with knees slightly bent
2. Side-lying on the right side
3. Side-lying on the left side
4. Semi-Fowler’s position
4
A client with congestive heart failure (CHF) is
usually most comfortable and has the least
amount of difficulty with breathing when placed
in either a semi- Fowler’s, mid-Fowler’s, high-
Fowler’s, or standing position. Sitting and
standing positions cause organs to fall away from
the diaphragm, giving more room for the lungs to
expand. Right-side lying, left-side-lying, or back-
lying positions, even with the knees bent, are
inappropriate because they impede good lung
expansion
QUESTION PRACTICE
Q. A client is admitted to the emergency
department with chest pain that is consistent
with myocardial infarction based on elevated
troponin levels Heart sounds are normal and
vital signs are noted on the client’s chart. The
nurse should alert the health care provider
because these changes are most consistent with
which complication? Refer to chart.
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm
1
Cardiogenic shock occurs with severe damage
(more than 40%) to the left ventricle. Classic
signs include hypotension; a rapid pulse that
becomes weaker; decreased urine output; and
cool, clammy skin. Respiratory rate increases as
the body develops metabolic acidosis from shock.
Cardiac tamponade is accompanied by distant,
muffled heart sounds and prominent neck
vessels. Pulmonary embolism presents suddenly
with severe dyspnea accompanying the chest
pain. Dissecting aortic aneurysms usually are
accompanied by back pain
QUESTION PRACTICE
Q. A client admitted to the hospital with chest pain
and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which
medication would need to be withheld for 24
hours before the procedure and for 48 hours after
the procedure?
1. Glipizide
2. Metformin
3. Repaglinide
4. Regular insulin
2
Metformin needs to be withheld 24 hours before
and for 48 hours after cardiac catheterization
because of the injection of contrast medium
during the procedure. If the contrast medium
affects kidney function, with metformin in the
system the client would be at increased risk for
lactic acidosis. The medications in the remaining
options do not need to be withheld 24 hours
before and 48 hours after cardiac catheterization
QUESTION PRACTICE
 Q. Aclient in sinus bradycardia, with a heart rate
of 45 beats/minute, complains of dizziness and
has a blood pressure of 82/60 mm Hg. Which
prescription should the nurse anticipate will be
prescribed?
1. Administer digoxin.
2. Defibrillate the client.
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing
4
Sinus bradycardia is noted with a heart rate less
than 60 beats per minute. This rhythm becomes
a concern when the client becomes symptomatic.
Hypotension and dizziness are signs of decreased
cardiac output. Transcutaneous pacing provides a
temporary measure to increase the heart rate
and thus perfusion in the symptomatic client.
Defibrillation is used for treatment of pulseless
ventricular tachycardia and ventricular
fibrillation. Digoxin will further decrease the
client’s heart rate. Continuing to monitor the
client delays necessary intervention.
QUESTION PRACTICE
Q. The nurse in a medical unit is caring for a client with
heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles and the
nurse suspects pulmonary edema. The nurse
immediately asks another nurse to contact the health
care provider and prepares to implement which
priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler’s side-lying position
1,2,3,4
Pulmonary edema is a life-threatening event thatcan
result from severe heart failure. In pulmonary edema,
the left ventricle fails to eject sufficient blood, and
pressuremincreases in the lungs because of the
accumulated blood. Oxygen is always prescribed, and
the client is placed in a high Fowler’s position to ease
the work of breathing. Furosemide, a rapid-acting
diuretic, will eliminate accumulated fluid. A Foley
catheter is inserted to measure output accurately.
Intravenously administered morphine sulfate reduces
venous return (preload), decreases anxiety, and also
reduces the work of breathing. Transporting the client
to the coronary care unit is not a priority
intervention. In fact, this may not be necessary at all
if the client’s response to treatment is successful.
QUESTION PRACTICE
Q. A client with myocardial infarction suddenly
becomes tachycardic, shows signs of air hunger,
and begins coughing frothy, pink-tinged sputum.
Which finding would the nurse anticipate
whenauscultating the client’s breath sounds?
1. Stridor
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds
2
Pulmonary edema is characterized by extreme
breathlessness, dyspnea, air hunger, and the
production of frothy, pink-tinged sputum.
Auscultation of the lungs reveals crackles.
Rhonchi and diminished breath sounds are not
associated with pulmonary edema. Stridor is a
crowing sound associated with laryngospasm or
edema of the upper airway.
QUESTION PRACTICE
Q. A client with myocardial infarction is developing
cardiogenic shock. Because of the risk of
myocardial ischemia, what condition should the
nurse carefully assess the client for?
1. Bradycardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure
2
Classic signs of cardiogenic shock as they relate to
myocardial ischemia include low blood pressure
and tachycardia. The central venous pressure
would rise as the backward effects of the severe
left ventricular failure became apparent.
Dysrhythmias commonly occur as a result of
decreased oxygenation and severe damage to
greater than 40% of the myocardium.
QUESTION PRACTICE
Q. A client who had cardiac surgery 24 hours ago has
had a urine output averaging 20 mL/hour for 2 hours.
The client received a single bolus of 500 mL of
intravenous fluid. Urine output for the subsequent
hour was 25 mL. Daily laboratory results indicate
that the blood urea nitrogen level is 45 mg/dL(16
mmol/L) and the serum creatinine level is 2.2 mg/dL
(194 mcmol/L). On the basis of these findings, the
nurse would anticipate that the client is at risk for
which problem?
1. Hypovolemia
2. Acute kidney injury
3. Glomerulonephritis
4. Urinary tract infection
2
 The client who undergoes cardiac surgery is at risk
for renal injury from poor perfusion, hemolysis, low
cardiac output, or vasopressor medication therapy.
Renal injury is signaled by decreased urine output
and increased blood urea nitrogen (BUN) and
creatinine levels. Normal reference levels are BUN,
10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine:
male, 0.6–1.2 mg/dL (53–106 mcmol/L) and female
0.5–1.1 mg/dL (44–97 mcmol/L). The client may need
medications to increase renal perfusion and possibly
could need peritoneal dialysis or hemodialysis. No
data in the question indicate the presence of
hypovolemia, glomerulonephritis, or urinary tract
infection.
QUESTION PRACTICE
Q. The nurse is reviewing an electrocardiogram
rhythm strip. The P waves and QRS complexes
are regular. The PRinterval is 0.16 seconds, and
QRS complexes measure 0.06 seconds. The
overall heart rate is 64 beats/minute. Which
action should the nurse take
1. Check vital signs.
2. Check laboratory test results.
3. Notify the health care provider.
4. Continue to monitor for any rhythm change.
4
Normal sinus rhythm is defined as a regular
rhythm, with an overall rate of 60 to 100
beats/minute. The PR and QRS measurements
are normal, measuring between 0.12 and 0.20
seconds and 0.04 and 0.10 seconds, respectively.
There are no irregularities in this rhythm
currently, so there is no immediate need to check
vital signs or laboratory results, or to notify the
health care provider. Therefore, the nurse would
continue to monitor the client for any rhythm
change.
QUESTION PRACTICE
Q. A client is wearing a continuous cardiac
monitor, which begins to sound its alarm. The
nurse sees no electrocardiographic complexes on
the screen. Which is the priority nursing action?
1. Call a code.
2. Call the health care provider.
3. Check the client’s status and lead placement.
4. Press the recorder button on the
electrocardiogram console.
3
Sudden loss of electrocardiographic complexes
indicates ventricular asystole or possibly
electrode displacement. Accurate assessment of
the client and equipment is necessary to
determine the cause and identify the appropriate
intervention. The remaining options are
secondary to client assessment.
QUESTION PRACTICE
Q. The nurse is watching the cardiac monitor and
notices that the rhythm suddenly changes. There
are no P waves, the QRS complexes are wide, and
the ventricular rate is regular but more than 140
beats/minute. The nurse determines that the
client is experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions
3
Ventricular tachycardia is characterized by the
absence of P waves, wide QRS complexes (longer
than 0.12 seconds), and typically a rate between
140 and 180 impulses/minute. The rhythm is
regular.
QUESTION PRACTICE
Q. A client has frequent bursts of ventricular
tachycardia on the cardiac monitor. What should
the nurse be most concerned about with this
dysrhythmia?
1. It can develop into ventricular fibrillation at any
time.
2. It is almost impossible to convert to a normal
rhythm.
3. It is uncomfortable for the client, giving a sense
of impending doom.
4. It produces a high cardiac output that quickly
leads to cerebral and myocardial ischemia.
1
Ventricular tachycardia is a life-threatening
dysrhythmia that results from an irritable
ectopic focus that takes over as the pacemaker
for the heart. The low cardiac output that results
can lead quickly to cerebral and myocardial
ischemia. Clients frequently experience a feeling
of impending doom. Ventricular tachycardia is
treated with antidysrhythmic medications,
cardioversion (if the client is awake), or
defibrillation (loss of consciousness). Ventricular
tachycardia can deteriorate into ventricular
fibrillation at any time.
QUESTION PRACTICE
Q. A client is having frequent premature
ventricular contractions. The nurse should place
priority on assessment of which item?
1. Sensation of palpitations
2. Causative factors, such as caffeine
3. Blood pressure and oxygen saturation
4. Precipitating factors, such as infection
3
Premature ventricular contractions can cause
hemodynamic compromise. Therefore, the
priority is to monitor the blood pressure and
oxygen saturation. The shortened ventricular
filling time can lead to decreased cardiac output.
The client may be asymptomatic or may feel
palpitations. Premature ventricular contractions
can be caused by cardiac disorders; states of
hypoxemia; any number of physiological
stressors, such as infection, illness, surgery, or
trauma; and intake of caffeine, nicotine, or
alcohol.
QUESTION PRACTICE
Q. The client has developed atrial fibrillation, with
a ventricular rate of 150 beats/minute. The nurse
should assess the client for which associated
signs and/or symptoms?
1. Flat neck veins
2. Nausea and vomiting
3. Hypotension and dizziness
4. Hypertension and headache
3
The client with uncontrolled atrial fibrillation with
a ventricular rate more than 100 beats/minute is
at risk for low cardiac output because of loss of
atrial kick. The nurse assesses the client for
palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness,
dizziness, syncope, shortness of breath, and
distended neck veins
QUESTION PRACTICE
Q. The nurse is watching the cardiac monitor, and
a client’s rhythm suddenly changes. There are no
P waves; instead, there are fibrillatory waves
before each QRS complex. How should the nurse
correctly interpret the client’s heart rhythm?
1. Atrial fibrillation
2. Sinus tachycardia
3. Ventricular fibrillation
4. Ventricular tachycardia
1
Atrial fibrillation is characterized by a loss of P
waves and fibrillatory waves before each QRS
complex. The atria quiver, which can lead to
thrombus formation.
QUESTION PRACTICE
Q. The nurse is assisting to defibrillate a client in
ventricular fibrillation. After placing the pad on
the client’s chest and before discharge, which
intervention is a priority?
1. Ensure that the client has been intubated.
2. Set the defibrillator to the “synchronize” mode.
3. Administer an amiodarone bolus intravenously.
4. Confirm that the rhythm is actually ventricular
fibrillation.
4
Until the defibrillator is attached and charged, the
client is resuscitated by using cardiopulmonary
resuscitation. Once the defibrillator has been
attached, the electrocardiogram is checked to
verify that the rhythm is ventricular fibrillation
or pulseless ventricular tachycardia. Leads also
are checked for any loose connections. A
nitroglycerin patch, if present, is removed. The
client does not have to be intubated to be
defibrillated. The machine is not set to the
synchronous mode because there is no underlying
rhythm with which to synchronize. Amiodarone
may be given subsequently but is not required
before defibrillation.
QUESTION PRACTICE
Q. A client in ventricular fibrillation is about to be
defibrillated. To convert this rhythm effectively,
the monophasic defibrillator machine should be
set at which energy level (in joules, J) for the first
delivery?
1. 50 J
2. 120 J
3. 200 J
4. 360 J
4
 The energy level used for all defibrillation
attempts with a monophasic defibrillator is 360
joules
QUESTION PRACTICE
Q. The nurse should evaluate that defibrillation of
a client was most successful if which observation
was made?
1. Arousable, sinus rhythm, blood pressure (BP)
116/72 mm Hg
2. Nonarousable, sinus rhythm, BP 88/60 mm Hg
3. Arousable, marked bradycardia, BP 86/ 54 mm
Hg
4. Nonarousable, supraventricular tachycardia, BP
122/60 mm Hg
1
After defibrillation, the client requires continuous
monitoring of electrocardiographic rhythm,
hemodynamic status, and neurological status.
Respiratory and metabolic acidosis develop
during ventricular fibrillation because of lack of
respiration and cardiac output. These can cause
cerebral and cardiopulmonary complications.
Arousable status, adequate BP, and a sinus
rhythm indicate successful response to
defibrillation.
QUESTION PRACTICE
Q. The nurse is evaluating a client’s response to
cardioversion. Which assessment would be the
priority?
1. Blood pressure
2. Status of airway
3. Oxygen flow rate
4. Level of consciousness
2
Nursing responsibilities after cardioversion include
maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs
and level of consciousness, and dysrhythmia
detection.
QUESTION PRACTICE
Q. The nurse is caring for a client who has just had
implantation of an automatic internal
cardioverter-defibrillator. The nurse should
assess which item based on priority?
1. Anxiety level of the client and family
2. Presence of a MedicAlert card for the client to
carry
3. Knowledge of restrictions on postdischarge
physical activity
4. Activation status of the device, heart rate cutoff,
and number of shocks it is programmed to deliver
4
The nurse who is caring for the client after
insertion of an automatic internal cardioverter-
defibrillator needs to assess device settings,
similar to after insertion of a permanent
pacemaker. Specifically, the nurse needs to know
whether the device is activated, the heart rate
cutoff above which it will fire, and the number of
shocks it is programmed to deliver. The
remaining options are also nursing interventions
but are not the priority.
QUESTION PRACTICE
Q. A client’s electrocardiogram strip shows atrial
and ventricular rates of110 beats/minute. The PR
interval is 0.14 seconds, the QRS complex
measures 0.08 seconds, and the PP and RR
intervals are regular. How should the nurse
correctly interpret this rhythm?
1. Sinus tachycardia
2. Sinus bradycardia
3. Sinus dysrhythmia
4. Normal sinus rhythm
1
Sinus tachycardia has the characteristics of normal
sinus rhythm, including a regular PP interval
and normal width
R and QRS intervals; however, the rate is the
differentiating factor. In sinus tachycardia, the
atrial and ventricular rates are greater than 100
beats/minute.
QUESTION PRACTICE
Q. The nurse is assessing the neurovascular status of a
client who returned to the surgical nursing unit 4
hours ago after undergoing aortoiliac bypass graft.
The affected leg is warm, and the nurse notes redness
and edema. The pedal pulse is palpable and
unchanged from admission. How should the nurse
correctly interpret the client’s neurovascular status?
1. The neurovascular status is normal because of
increased blood flow through the leg.
2. The neurovascular status is moderately impaired,
and the surgeon should be called.
3. The neurovascular status is slightly deteriorating
and should be monitored for another hour.
4. The neurovascular status is adequate from an
arterial approach, but venous complications are
arising.
1
An expected outcome of aortoiliac bypass graft
surgeryis warmth, redness, and edema in the
surgical extremity because of increased blood
flow. The remaining options are incorrect
interpretations.
QUESTION PRACTICE
Q. The nurse is evaluating the condition of a client
after pericardio centesis performed to treat
cardiac tamponade. Which observation would
indicate that the procedure was effective?
1. Muffled heart sounds
2. A rise in blood pressure
3. Jugular venous distention
4. Client expressions of dyspnea
2
Following pericardio centesis, the client usually
expresses immediate relief. Heart sounds are no
longer muffled or distant and blood pressure
increases. Distended neck veins are a sign of
increased venous pressure, which occurs with
cardiac tamponade.
QUESTION PRACTICE
Q. The nurse is caring for a client who had a resection
of an abdominal aortic aneurysm yesterday. The
client has an intravenous (IV) infusion at a rate of
150 mL/hour, unchanged for the last 10 hours. The
client’s urine output for the last 3 hours has been 90,
50, and 28 mL (28 mL is most recent). The client’s
blood urea nitrogen level is 35 mg/dL (12.6 mmol/L)
and the serum creatinine level is 1.8 mg/dL (159
mcmol/L), measured this morning. Which nursing
action is the priority?
1. Check the urine specific gravity.
2. Call the health care provider (HCP).
3. Put the IV line on a pump so that the infusion rate is
sure to stay stable.
4. Check to see if the client had a blood sample for a
serum albumin level drawn.
2
Following abdominal aortic aneurysm resection or
repair, the nurse monitors the client for signs of
acute kidney injury. Acute kidney injury can
occur because often much blood is lost during the
surgery and, depending on the aneurysm
location, the renal arteries may be hypoperfused
for a short period during surgery. Normal
reference levels are BUN, 10 to 20 mg/dL (3.6 to
7.1 mmol/L), and creatinine: male, 0.6–1.2 mg/dL
(53–106 mcmol/L) and female 0.5–1.1 mg/dL (44–
97 mcmol/L). Options 1 and 4 are not associated
with the data in the question. The IV should have
already been on a pump. Urine output lower than
30 mL/hour is reported to the HCP.
QUESTION PRACTICE
Q. A client with variant angina is scheduled to receive
an oral calcium channel blocker twice daily.Which
statement by the client indicates the need for further
teaching
1. “I should notify my doctor ifmy feet or legs start to
swell.”
2. “My doctor told me to call his office if my pulse rate
decreases below 60.”
3. “Avoiding grapefruit juice will definitely be a
challenge for me, since I usually drink it every
morning with breakfast.”
4. “My spouse told me that since I have developed this
problem, we are going to stop walking in the mall
every morning.”
4
Variant angina, or Prinzmetal’s angina, is prolonged
and severe and occurs at the same time each day,
most often at rest. The pain is a result of coronary
artery spasm. The treatment of choice is usually a
calcium channel blocker, which relaxes and dilates
the vascular smooth muscle, thus relieving the
coronary artery spasm in variant angina. Adverse
effects can include peripheral edema, hypotension,
bradycardia, and heart failure. Grapefruit juice
interacts with calcium channel blockers and should be
avoided. If bradycardia occurs, the client should
contact the health care provider. Clients should also
be taught to change positions slowly to prevent
orthostatic hypotension. Physical exertion does not
cause this type of angina; therefore, the client should
be able to continue morning walks with his or her
spouse.
QUESTION PRACTICE
Q. The nurse notes that a client with sinus rhythm
has a premature ventricular contraction that
falls on the T wave of the preceding beat. The
client’s rhythm suddenly changes to one with no
P waves, no definable QRS complexes, and coarse
wavy lines of varying amplitude. How should the
nurse correctly interpret this rhythm?
1. Asystole
2. Atrial fibrillation
3. Ventricular fibrillation
4. Ventricular tachycardia
3
Ventricular fibrillation is characterized by irregular
chaotic undulations of varying amplitudes.
Ventricular fibrillation has no measurable rate
and no visible P waves or QRS complexes and
results from electrical chaos in the ventricles.
QUESTION PRACTICE
Q. A client receiving thrombolytic therapy with a
continuous infusion of alteplase suddenly
becomes extremely anxious and complains of
itching. The nurse hears stridor and notes
generalized urticaria and hypotension. Which
nursing action is the priority?
1. Administer oxygen and protamine sulfate.
2. Cut the infusion rate in half and sit the client up
in bed.
3. Stop the infusion and call for the Rapid Response
Team (RRT).
4. Administer diphenhydramine and epinephrine
and continue the infusion.
3
The client is experiencing an anaphylactic reaction.
Therefore, the priority action is to stop the
infusion and notify the RRT. The health care
provider should be contacted once the client has
been stabilized. The client may be treated with
epinephrine, antihistamines, and corticosteroids
as prescribed, but the infusion should not be
continued.
QUESTION PRACTICE
Q. A client is prescribed nicotinic acid for
hyperlipidemia and the nurse provides
instructions to the client about the medication.
Which statement by the client indicates an
understanding of the instructions?
1. “It is not necessary to avoid the use of alcohol.”
2. “The medication should be taken with meals to
decrease flushing.”
3. “Clay-colored stools are a common side effect and
should not be of concern.”
4. “Ibuprofen IB taken 30 minutes before the
nicotinic acid should decrease the flushing.”
4
Flushing is an adverse effect of this medication.
Aspirin or a nonsteroidal antiinflammatory drug
can be taken 30 minutes prior to taking the
medication to decrease flushing. Alcohol
consumption needs to be avoided because it will
enhance this effect. The medication should be
taken with meals to decrease gastrointestinal
upset; however, taking the medication with meals
has no effect on the flushing. Clay-colored stools
are a sign of hepatic dysfunction and should be
reported to the health care provider (HCP)
immediately.
QUESTION PRACTICE
Q. The nurse is planning to administer hydrochloro
thiazide to a client. The nurse should monitor for
which adverse effects related to the
administration of this medication?
1. Hypouricemia, hyperkalemia
2. Increased risk of osteoporosis
3. Hypokalemia, hyperglycemia, sulfa allergy
4. Hyperkalemia, hypoglycemia, penicillin allergy
3
Thiazide diuretics such as hydrochlorothiazide are
sulfa-based medications, and a client with a sulfa
allergy is at risk for an allergic reaction. Also,
clients are at risk for hypokalemia,
hyperglycemia, hypercalcemia, hyperlipidemia,
and hyperuricemia.
QUESTION PRACTICE
Q. Which client statement indicates an
understanding of the nurse’s instructions
concerning a Holter monitor?
1. “The only times the monitor should be taken off
is for showering and sleep.”
2. “The monitor will record my activities and
symptoms if an abnormal rhythm occurs.”
3. “The results from the monitor will be used to
determine the size and shape of my heart.”
4. “The monitor will record any abnormal heart
rhythms while I go about my usual activities.”
4

4 The cardiac rhythm is monitored and rhythm

disturbances documented; disturbances are
stored, printed, and then analyzed in relation to
the client’s activity/symptom diary.
1 The monitor must remain in place constantly for
accurate recordings. 2 The client must keep a
record of activities and symptoms while the
monitor records cardiac rhythm disturbances,
and then an analysis of correlations between the
two is made. 3 A chest radiograph, not a Holter
monitor, will reveal the size and contour of the
heart.
QUESTION PRACTICE
Q. A client with a history of dysrhythmias is to
wear a Holter monitor for 24 hours on an
outpatient basis. What should the nurse teach
the client to do while wearing the monitor?
1. Discontinue medications.
2. Avoid using a microwave oven.
3. Keep a written account of activities.
4. Record the blood pressure periodically
3

3 A day’s activities should be recorded so that

they can be compared with the occurrence
of dysrhythmias.

 1 It is not necessary to discontinue

medications. 2 It is not necessary to avoid
using a microwave oven. 4 Obtaining blood
pressure readings while wearing a Holter
monitor is not necessary
QUESTION PRACTICE
Q. A client with a dysrhythmia is admitted to
telemetry for observation. In the morning the
client asks for a cup of coffee. What is the nurse’s
best response?
1. “Hot drinks such as coffee are not good for your
heart.”
2. “Coffee is not permitted on the diet that was
ordered for you.”
3. “You cannot have coffee. I can bring you a cup of
tea if you like.”
4. “Coffee has caffeine that can affect your heart. It
should be avoided.”
4

4 Caffeine is a stimulant that causes

vasoconstriction and is contraindicated for
a client with a dysrhythmia.
1, 2 Although this is a true statement, it does
not provide information as to why it is not
good for the heart. Adherence to a medical
regimen increases when the client
understands the rationale for
recommendations. 3 Tea contains caffeine
and should be avoided by a client with a
dysrhythmia.
QUESTION PRACTICE
Q. A client who had several episodes of chest pain is
scheduled for an exercise electrocardiogram.
Which explanation should the nurse include
when teaching the client about this procedure?
1. “This is a noninvasive test to check your heart’s
response to physical activity.”
2. “This test is the definitive method to identify the
actual cause of your chest pain.”
3. “The findings of this test will be of minimal
assistance in the treatment of angina.”
4. “The findings from this minimally invasive test
will show how your body reacts to exercise.”
1

1 This test evaluates the heart’s ability to

meet the need for additional oxygen in
response to the stress of exercising.
Changes in the ECG identify dysrhythmias
and ST changes indicative of myocardial
ischemia.
2 This test assists in the differential diagnosis
of chest pain; the diagnosis of heart disease
is made via the results of a variety of
diagnostic procedures and laboratory tests.
3 This is a valuable test that will influence
the diagnosis and treatment of heart
disease. 4 This is a noninvasive test.
QUESTION PRACTICE
Q. A client is admitted with chest pain unrelieved by
nitroglycerin, an elevated temperature, decreased
blood pressure, and diaphoresis. A myocardial
infarction is diagnosed. Which should the nurse
consider as a valid reason for one of this client’s
physiologic responses?
1. Parasympathetic reflexes from the infarcted
myocardium cause diaphoresis.
2. Inflammation in the myocardium causes a rise in the
systemic body temperature.
3. Catecholamines released at the site of the infarction
cause intermittent localized pain.
4. Constriction of central and peripheral blood vessels
causes a decrease in blood pressure.
2

2 Temperature may increase within the first

24 hours as a result of the inflammatory
response to tissue destruction and persist
as long as a week.
1 Diaphoresis is caused by activation of the
sympathetic, not parasympathetic, nervous
system and may indicate cardiogenic shock.
3 Pain is persistent and constant, not
intermittent; it is caused by oxygen
deprivation and the release of lactic acid. 4
The blood pressure increases initially but
then drops because there is a decrease in
cardiac output.
QUESTION PRACTICE
Q. What must the nurse do to determine a client’s
pulse pressure?
1. Multiply the heart rate by the stroke volume.
2. Subtract the diastolic from the systolic reading.
3. Determine the mean blood pressure by averaging
the two.
4. Calculate the difference between the apical and
radial rate.
2

2 Pulse pressure is obtained by subtracting

the diastolic from the systolic reading after
the blood pressure has been recorded.
1 This is the definition of cardiac output; it is
not the pulse pressure. 3 This is not pulse
pressure. 4 This is the pulse deficit
QUESTION PRACTICE
Q. After surgery for insertion of a coronary artery
bypass graft (CABG), a client develops a
temperature of 102° F (38.8° C). What priority
concern related to elevated temperatures
does a nurse consider when notifying the
health care provider about the client’s
temperature?
1. A fever may lead to diaphoresis.
2. A fever increases the cardiac output.
3. An increased temperature indicates cerebral
edema.
4. An increased temperature may be a sign of
hemorrhage
2

2 Temperatures of 102° F (38° C) or greater

lead to an increased metabolism and
cardiac workload.

 1 Although diaphoresis is related to an

elevated temperature, it is not the reason
for notifying the health care provider. 3 An
elevated temperature is not an early sign of
cerebral edema. Open heart surgery is not
associated with cerebral edema. 4 Fever is
unrelated to hemorrhage; in hemorrhage
with shock, the temperature decreases.
QUESTION PRACTICE
Q. A nurse is teaching a group of clients with
peripheral vascular disease about a smoking
cessation program. Which physiologic effect of
nicotine should the nurse explain to the group?
1. Constriction of the superficial vessels dilates the
deep vessels.
2. Constriction of the peripheral vessels increases
the force of flow.
3. Dilation of the superficial vessels causes
constriction of collateral circulation.
4. Dilation of the peripheral vessels causes reflex
constriction of visceral vessels.
2

2 Constriction of the peripheral blood vessels

and the resulting increase in blood pressure
impair circulation and limit the amount of
oxygen being delivered to body cells,
particularly in the extremities.
1 Nicotine constricts all peripheral vessels,
not just superficial ones; its primary action
is vasoconstriction; it will not dilate deep
vessels. 3, 4 Nicotine constricts rather than
dilates peripheral vessels.
QUESTION PRACTICE
Q. A nurse is caring for a client with chronic
occlusive arterial disease. What precipitating
cause is the nurse most likely to identify for
the development of ulceration and
gangrenous lesions?
1. Emotional stress, which is short-lived
2. Poor hygiene and limited protein intake
3. Stimulants such as coffee, tea, or cola drinks
4. Trauma from mechanical, chemical, or thermal
sources
4

4 Diminished sensation decreases awareness of

injury. Injured tissue cannot heal properly
because of cellular deprivation of oxygen and
nutrients; ulceration and gangrene may result.

1 Emotional stress does not cause tissue injury;

however, because of vasoconstriction, it may
prolong healing. 2 Inadequate hygiene is only
one stress that may cause tissue trauma;
protein is not related to this disease. 3 Although
caffeine stimulates the peripheral vessels to
constrict, limiting oxygen to cells, it is not the
major cause of ulceration.
QUESTION PRACTICE
Q. A client is prescribed prolonged bed rest
after surgery. Which complication does the
nurse expect to prevent by teaching this
client to avoid pressure on the popliteal
space?
1. Cerebral embolism
2. Pulmonary embolism
3. Dry gangrene of a limb
4. Coronary vessel occlusion
2

2 The pulmonary capillary beds are the first

small vessels that the embolus encounters
once it is released from the calf veins.
1, 4 This will not occur because the embolus
will enter the pulmonary system first. 3 Dry
gangrene occurs when the arterial rather
than the venous circulation is
compromised.
QUESTION PRACTICE
Q. A nurse inspects a two-day-old intravenous site
and identifies erythema, warmth, and mild
edema. The client reports tenderness when the
area is palpated. What should the nurse do first?
1. Irrigate the IV tubing.
2. Discontinue the infusion.
3. Slow the rate of the infusion.
4. Obtain a prescription for an analgesic.
2

2 The clinical findings indicate the presence

of inflammation. The intravenous catheter
should be removed to prevent the
development of thrombophlebitis.
1, 3 This is unsafe. It may further irritate the
vein and precipitate a thrombophlebitis. 4
Although this may relieve the discomfort, it
is not an intervention that will resolve the
problem.
QUESTION PRACTICE
Q. A client being treated for hypertension reports
having a persistent hacking cough. What class of
antihypertensive should the nurse identify as a
possible cause of this response when reviewing a
list of this client’s medications?
1. ACE inhibitors
2. Thiazide diuretics
3. Calcium channel blockers
4. Angiotensin receptor blockers
1

1 ACE (angiotensin-converting enzyme)

increases the sensitivity of the cough reflex,
leading to the common adverse effect
sometimes referred to as an ACE cough.
2, 3, 4 A cough is not a side effect of this
category of medication.
QUESTION PRACTICE
Q.What client response indicates to the nurse that
a vasodilator medication is effective?
1. Pulse rate decreases from 110 to 75
2. Absence of adventitious breath sounds
3. Increase in the daily amount of urine produced
4. Blood pressure changes from 154/90 to 126/72
4

4 Vasodilation will lower the blood pressure.

1 The pulse rate is not decreased and may
increase. 2 Breath sounds are not directly
affected by vasodilation, although
vasodilator medications can decrease
preload and afterload, which could
indirectly affect breath sounds in heart
failure. 3 The urine output is not affected
immediately, although control of blood
pressure can help preserve renal function
over time.
QUESTION PRACTICE
Q. Amlodipine (Norvasc) is prescribed for a client
with hypertension. Which response to the
medication should the nurse instruct the client to
report to the health care provider?
1. Blurred vision
2. Dizziness on rising
3. Excessive urination
4. Difficulty breathing
4

4 Dyspnea may indicate development of

pulmonary edema, which is a life-
threatening condition.
1 This CNS side effect may occur in some
people, but it is not life-threatening. 2, 3
This is a common side effect of this
medication, which is not life-threatening.
QUESTION PRACTICE
Q. Which nursing action is most important when
caring for a client after a cardiac catheterization?
1. Provide for rest.
2. Administer oxygen.
3. Check a pulse distal to the insertion site.
4. Assess the electrocardiogram every fifteen
minutes.
3

3 The pulse should be assessed because the

trauma at the insertion site may interfere
with blood flow distal to the site. There is
also danger of bleeding.
1 Rest is not a priority, although the
extremity in which the catheter was
inserted usually is immobilized for a period
of time to prevent bleeding at the insertion
site. 2 This is determined on an individual
basis; it is not routine. 4 The client will be
on a cardiac monitor, which will allow for
continuous monitoring.
QUESTION PRACTICE
Q. For which common complication of myocardial
infarction should the nurse monitor clients in the
coronary care unit?
1. Dysrhythmia
2. Hypokalemia
3. Anaphylactic shock
4. Cardiac enlargement
1

1 Myocardial infarction (MI) may cause

increased irritability of tissue or
interruption of normal transmission of
impulses. Dysrhythmias occur in about 90%
of clients after an MI.
2 Hypokalemia may result when clients are
taking cardiac glycosides and diuretics; this
is a complication associated with therapy,
not a pathologic entity related to the MI
itself. 3 Anaphylactic shock is caused by an
allergic reaction, not by an MI. 4 Cardiac
enlargement is a slow process, so it will not
be evident in the coronary care unit.
QUESTION PRACTICE
Q. A nurse prepares a client for insertion of a
pulmonary artery catheter. What information can
be obtained from monitoring the pulmonary
artery pressure?
1. Stroke volume
2. Venous pressure
3. Coronary artery patency
4. Left ventricular functioning
4

4 The catheter is placed in the pulmonary artery.

Information regarding left ventricular function
is obtained when the catheter balloon is
inflated.
1 Information on stroke volume, the amount of
blood ejected by the left ventricle with each
contraction, is not provided by a pulmonary
catheter. 2 Although a central venous pressure
reading can be obtained with the pulmonary
catheter, it is not as specific as a pulmonary
wedge pressure, which reflects pressure in the
left side of the heart. 3 The patency of the
coronary arteries usually is evaluated by
cardiac catheterization.
QUESTION PRACTICE
Q. What specifically should the nurse monitor
when a client is receiving a platelet aggregation
inhibitor such as clopidogrel (Plavix)?
1. Nausea
2. Epistaxis
3. Chest pain
4. Elevated temperature
2

2 The high vascularity of the nose, combined

with its susceptibility to trauma (e.g.,
sneezing, nose blowing), makes it a frequent
site of hemorrhage.
1, 3, 4 This response usually is not associated
with anticoagulant therapy.
Q. A client with pulmonary edema has been on
diuretic therapy. The client has an order for
additional furosemide (Lasix) in the amount of 40
mg IV push. Knowing that the client also will be
started on digoxin (Lanoxin), a nurse checks the
client’s most recent:
A. Digoxin level
B. Sodium level
C. Potassium level
D. Creatinine level
 Correct Answer: C. Potassium level
 The serum potassium level is measured in the client receiving digoxin and
furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in
the client with hypokalemia. Hypokalemia also predisposes the client to
ventricular dysrhythmias. Toxicity can also occur at lower levels, especially in
the setting of other risk factors such as low body weight, advanced age,
decreased renal function, and hypokalemia. Risk of hypokalemia increases with
the use of a high dose of furosemide, decreased oral intake of potassium, in
patients with hyperaldosteronism states (liver abnormalities or licorice
ingestion) or concomitant use of corticosteroid, ACTH, and laxatives.
 Option A: Digoxin has a narrow therapeutic index. The recommended serum
levels stand between 0.8 to 2 ng/mL. When measuring a digoxin serum level, it
is essential to draw blood at least 6 to 8 hours after the last dose. The toxicity
increases as the serum drug levels increase above 2.0 ng/mL.
 Option B: According to Beers Criteria, caution is necessary when
administering diuretics to patients 65 years and older to avoid potential
adverse effects of inducing hyponatremia by causing or exacerbating syndrome
of inappropriate antidiuretic hormone secretion (SIADH); therefore, close
monitoring of serum sodium is advisable at initiation or during the dose
adjustment in older adults.
 Option D: In patients with an advanced renal disease with fluid overload the
patients should be closely monitored for oliguria, azotemia, and volume status;
and if either oliguria or azotemia develops the furosemide should be
discontinued to prevent kidney injury.
QUESTION PRACTICE
Q. A client’s electrocardiogram strip shows atrial
and ventricular rates of 80 complexes per minute.
The PR interval is 0.14 second, and the QRS
complex measures 0.08 second. The nurse
interprets this rhythm is:
A. Normal sinus rhythm
B. Sinus bradycardia
C. Sinus tachycardia
D. Sinus dysrhythmia
 Correct Answer: A. Normal sinus rhythm
 Normal sinus rhythm (NSR) is another name for the normal heart rhythm. The
heartbeat is controlled by regular electric signals (also called electrical
impulses) that spontaneously arise in a structure called the sinus node. These
signals then spread across the heart starting at the atria and then the
ventricles. The heart’s rhythm is referred to as “sinus rhythm” because the
electrical impulse is generated in the sinus node. A normal sinus rhythm is one
in which the rate of firing is not too fast nor too slow.
 Option B: Sinus bradycardia occurs during sleep, for example, when most
people experience a dip in heart rate to well below 60 beats per minute.
Trained athletes can have resting heart rates in the 40s even while awake.
However, when a person’s heart rate is too low while they’re awake, they may
have a disorder called sinus node disease, or sick sinus syndrome, which can
cause them to get tired easily and experience other symptoms such as
lightheadedness and fainting.
 Option C: Sinus rhythm that is at the high end of the normal range is referred
to as sinus tachycardia. It can be normal for the heart rate to speed up during
exercise, as this allows it to pump extra blood throughout the body to fuel
physical exertion.
 Option D: A cardiac dysrhythmia (also called an arrhythmia) is an abnormal
rhythm of your heartbeat. It can be slower or faster than a normal heart rate.
It can also be irregular. It can be life-threatening if the heart cannot pump
enough oxygen-rich blood to the heart itself or the rest of the body.
QUESTION PRACTICE
Q. A home care nurse is making a routine visit to a
client receiving digoxin (Lanoxin) in the
treatment of heart failure. The nurse would
particularly assess the client for:
A. Thrombocytopenia and weight gain
B. Anorexia, nausea, and visual disturbances
C. Diarrhea and hypotension
D. Fatigue and muscle twitching
 Correct Answer: B. Anorexia, nausea, and visual disturbances
 The first signs and symptoms of digoxin toxicity in adults include abdominal
pain, N/V, visual disturbances (blurred, yellow, or green vision, halos around
lights), bradycardia, and other dysrhythmias. Symptoms may be mild and
include nausea, vomiting, and anorexia. Visual side effects might include color
changes, also known as xanthopsia. But yellow or green-tinted vision is usually
associated with digoxin toxicity. Patients may also highlight blurry vision or
photopsia. At toxic levels, digoxin is proarrhythmic.
 Option A: An impaired ventricle is more prone to ventricular
tachyarrhythmias and ectopy. Abnormally high levels of digoxin stimulate
atrial activation, thus atrial tachycardias, which, in a patient on digoxin, is
highly suggestive of toxicity. These atrial tachycardias are persistent and
resolve with a decrease in serum digoxin levels.
 Option C: Digoxin toxicity is clinically relevant as it can lead to fatal cardiac
arrhythmias. The estimated frequency is at about 0.8 to 4% of patients on
steady digoxin therapy. The rate of toxicity increases as serum digoxin
concentration reaches over 2.0 ng/ml.
 Option D: Electrocardiogram changes seen with digoxin demonstrate a
downsloping ST-segment depression, also known as a “reverse check” sign. The
ST segments may appear “scooped” without abnormal Q waves or T wave
inversions.[8] Regular intake of digoxin results in changes such as a decreased
QT interval, prolongation of the PR interval and T wave inversion or flattening.
QUESTION PRACTICE
Q. A client with angina complains that the angina
pain is prolonged and severe and occurs at the
same time each day, most often in the morning,
On further assessment a nurse notes that the
pain occurs in the absence of precipitating
factors. This type of anginal pain is best
described as:
 A. Stable angina

 B. Unstable angina

 C. Variant angina

 D. Nonanginal pain
 Correct Answer: C. Variant angina
 Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same
time each day, most often in the morning. Patients with vasospastic angina present with a
chronic pattern of episodes of chest pain at rest that last 5 to 15 minutes, from midnight to
early morning. Typically, the chest pain is not triggered by exertion or alleviated with rest
as is typical angina. Pain decreases with the use of short-acting nitrates. Often, the patient
is younger with few or no classical cardiovascular risk factors.
 Option A: Stable angina is induced by exercise and is relieved by rest or nitroglycerin
tablets. Stable angina is characterized by chest discomfort or anginal equivalent that is
provoked with exertion and alleviated at rest or with nitroglycerin. This is often one of the
first manifestations or warning signs of underlying coronary disease. As previously
mentioned, typical angina usually presents as chest discomfort or anginal equivalent that
is provoked with exertion and alleviated at rest or with nitroglycerin.
 Option B: Unstable angina occurs at lower and lower levels of activity and rest, is less
predictable and is often a precursor of myocardial infarction. Patients will often present
with chest pain, shortness of breath. The chest pain will often be described as pressure -
like, although it is not necessarily limited to this description. Nitroglycerin and aspirin
administration may also improve the pain. One distinguishing factor of unstable angina is
that the pain may not completely resolve with these reported relieving factors.
 Option D: It is important to distinguish between cardiac and non-cardiac chest discomfort.
Discussing the details of the patient’s symptoms will further guide this differentiation.
Relevant details include the quality, location, influencing factors, timing, and duration of
the pain
QUESTION PRACTICE
Q. The physician orders continuous intravenous
nitroglycerin infusion for the client with MI.
Essential nursing actions include which of the
following?
 A. Obtaining an infusion pump for the
medication.
 B. Monitoring BP q4h.

 C. Monitoring urine output hourly.

 D. Obtaining serum potassium levels daily.

 Correct Answer: A. Obtaining an infusion pump for the medication.
 IV nitro infusion requires an infusion pump for precise control of the
medication. When administered as a drip in the emergency room or ICU, its
effects are often very closely monitored via an arterial line for real-time blood
pressure monitoring. This vigilance is necessary to maximize the effectiveness
of the drip and provide rapid feedback on the patient’s condition.
 Option B: BP monitoring would be done with a continuous system, and more
frequently than every 4 hours. The drip is frequently used to treat acute
coronary syndromes, hypertensive emergency, and acute congestive heart
failure (CHF) exacerbations. When administered, its effect requires tight
monitoring. Some patients can be more sensitive to the hypotension caused by
nitrates, which can result in nausea, vomiting, diaphoresis, pallor, and collapse
even at therapeutic doses.
 Option C: Hourly urine outputs are not always required. Nitroglycerin is both
a protein-bound drug, and undergoes hepatic metabolism. Therefore it has
numerous drug interactions. Before prescribing, providers should determine if
the patient is taking any medications that may interact with nitroglycerin.
Common interactions include alteplase, heparin, tricyclic antidepressants, and
other anticholinergic drugs. Alcohol intake should also be limited.
 Option D: Obtaining serum potassium levels is not associated with
nitroglycerin infusion. Any testing does not currently monitor nitroglycerin
levels as its half-life is approximately 2 to 3 minutes, and the drug undergoes
rapid metabolism from the body. Continuous monitoring of blood pressure,
heart rate, respiratory rate, and oxygen saturation is recommended.
QUESTION PRACTICE
Q. Aspirin is administered to the client
experiencing an MI because of its:
 A. Antipyretic action

 B. Antithrombotic action

 C. Antiplatelet action

 D. Analgesic action
 Correct Answer: B. Antithrombotic action
 Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the
primary reason ASA is administered to the client experiencing an MI is its
antithrombotic action. Aspirin is a cyclooxygenase-1 (COX-1) inhibitor. It is a
modifier of the enzymatic activity of cyclooxygenase-2 (COX-2). Unlike other
NSAIDs (ibuprofen/naproxen), which bind reversibly to this enzyme, aspirin
binding is irreversible. It also blocks thromboxane A2 on platelets in an
irreversible fashion preventing platelet aggregation.
 Option A: Researchers hypothesize that due to the blocking of the COX
pathway, the arachidonic acids are shuttled into the lipoxygenase pathway. The
production of anti-inflammatory lipoxins is a result of the modification of
prostaglandin-endoperoxide synthase (PTGS2), also called COX-2, that results
in the production of lipoxins, most of which are anti-inflammatory.
 Option C: Plasma levels of aspirin can range from 3 to 10 mg/dL for
therapeutic doses to as high as 70 to 140 mg/dL for acute toxicity. Due to
delayed absorption of certain preparations, levels should be checked 4 hours
after consumption and every 2 hours after that until maximum levels are
reached.
 Option D: Salicylates have been derived from the willow tree bark. The
Sumerians were noted to have used remedies derived from the willow tree for
pain management as far back as 4000 years ago. Hippocrates used it for
managing pain and fever. He even utilized tea brewed from it for pain
management during childbirth.
QUESTION PRACTICE
Q. Which of the following is an expected outcome
for a client on the second day of hospitalization
after an MI?
 A. Has severe chest pain.

 B. Can identify risk factors for MI.

 C. Agrees to participate in a cardiac

rehabilitation walking program.
 D. Can perform personal self-care activities
without pain.
 Correct Answer: D. Can perform personal self-care activities without
pain.
 By day 2 of hospitalization after an MI, clients are expected to be able to
perform personal care without chest pain. Pain is a subjective experience and
must be described by the patient. Provides a baseline for comparison to aid in
determining the effectiveness of therapy, resolution, and progression of the
problem.
 Option A: Severe chest pain should not be present. Instruct the patient to
report pain immediately. Provide a quiet environment, calm activities, and
comfort measures. Approach the patient calmly and confidently. Decreases
external stimuli, which may aggravate anxiety and cardiac strain, limit coping
abilities and adjustment to the current situation.
 Option B: Day 2 hospitalization may be too soon for clients to be able to
identify risk factors for MI. Review history of previous angina, anginal
equivalent, or MI pain. Discuss family history if pertinent. Delay in reporting
pain hinders pain relief and may require an increased dosage of medication to
achieve relief. In addition, severe pain may induce shock by stimulating the
sympathetic nervous system, thereby creating further damage and interfering
with diagnostics and relief of pain.
 Option C: Day 2 hospitalization is too soon for the client to begin a walking
program, however, the client may be sitting up in a chair as part of the cardiac
rehabilitation program. Instruct the patient to do relaxation techniques: deep
and slow breathing, distraction behaviors, visualization, guided imagery. Assist
as needed.
QUESTION PRACTICE
Q. Which of the following reflects the principle on
which a client’s diet will most likely be based
during the acute phase of MI?
 A. Liquids as ordered

 B. Small, easily digested meals

 C. Three regular meals per day

 D. NPO
 Correct Answer: B. Small, easily digested meals
 Recommended dietary principles in the acute phase of MI include avoiding
large meals because small, easily digested foods are better tolerated. Fluids are
given according to the client’s needs, and sodium restrictions may be
prescribed, especially for clients with manifestations of heart failure.
Cholesterol restrictions may be ordered as well.
 Option A: Limit saturated fat and trans fat and replace them with the better
fats, monounsaturated and polyunsaturated. If there is a need to lower blood
cholesterol, reduce saturated fat to no more than 5 to 6 percent of total calories.
For someone eating 2,000 calories a day, that’s about 13 grams of saturated fat.
 Option C: Choose foods with less sodium and prepare foods with little or no
salt. To lower blood pressure, aim to eat no more than 2,300 milligrams of
sodium per day. Reducing daily intake to 1,500 mg is desirable because it can
lower blood pressure even further. If the client can’t meet these goals right now,
even reducing sodium intake by 1,000 mg per day can benefit blood pressure.
 Option D: Clients are not prescribed a diet of liquids only or NPO unless their
condition is very unstable. Choose poultry and fish without skin and prepare
them in healthy ways without added saturated and trans fat. If the client
chooses to eat meat, look for the leanest cuts available and prepare them in
healthy and delicious ways.
QUESTION PRACTICE
Q. Captopril may be administered to a client
with HF because it acts as a:
 A. Vasopressor

 B. Volume expander

 C. Vasodilator

 D. Potassium-sparing diuretic
 Correct Answer: C. Vasodilator
 ACE inhibitors have become the vasodilators of
choice in the client with mild to severe HF.
Vasodilator drugs are the only class of drugs
clearly shown to improve survival in overt heart
failure. ACEi improves heart failure by
decreasing afterload. Apart from decreasing the
afterload, it also reduces cardiac myocyte
hypertrophy. The Heart Outcomes Prevention
Evaluation (HOPE) Study demonstrated better
outcomes for those prescribed ACE inhibitors.
QUESTION PRACTICE
Q. Which of the following foods should the nurse
teach a client with heart failure to avoid or limit
when following a 2-gram sodium diet?
 A. Apples

 B. Tomato juice

 C. Whole wheat bread

 D. Beef tenderloin
 Correct Answer: B. Tomato juice
 Canned foods and juices, such as tomato juice,
are typically high in sodium and should be
avoided on a sodium-restricted diet. Canned and
processed foods, such as gravies, instant cereal,
packaged noodles, and potato mixes, olives,
pickles, soups, and vegetables are high in salt.
Choose the frozen item instead; or better yet,
choose fresh foods when you can. Cheeses, cured
meats (such as bacon, bologna, hot dogs, and
sausages), fast foods, and frozen foods also may
contain a lot of sodium.
QUESTION PRACTICE
Q. Which of the following arteries primarily feeds
the anterior wall of the heart?
 A. Circumflex artery

 B. Internal mammary artery

 C. Left anterior descending artery

 D. Right coronary artery

 Correct Answer: C. Left anterior
descending artery
 The left anterior descending artery is the
primary source of blood for the anterior wall of
the heart. The left anterior descending artery
(LAD) supplies the anterior two-thirds of the
septum. The LAD is one of two major branches of
the LMCA, with the other being the left
circumflex (LCx) coronary arteries. Combined,
these two supply blood to the left atrium and left
ventricle.
QUESTION PRACTICE
Q. Select-all-that-apply: What are the typical signs
and symptoms of infective endocarditis?

A. Hyperthermia
B. S4 gallop
C. Enlarged Spleen
D. Hyperkalemia
E. Substernal pain that radiates to the back
F. Heart failure
G. Cardiac Murmur
ACFG
 Hyperthermia
 Enlarged Spleen

 Heart failure

 Cardiac Murmur
QUESTION PRACTICE
Q. A client admitted to the hospital with chest pain
and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which
medication would need to be withheld for 24
hours before the procedure and for 48 hours after
the procedure?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)
4
 Metformin (Glucophage) needs to be withheld 24
hours before and for 48 hours after cardiac
catheterization because of the injection of
contrast medium during the procedure. If the
contrast medium affects kidney function, with
metformin in the system, the client would be at
increased risk for lactic acidosis. The medications
in the remaining options do not need to be
withheld 24 hours before and 48 hours after
cardiac catheterization.
QUESTION PRACTICE
 The nurse is monitoring a client with acute
pericarditis for signs of cardiac tamponade.
Which assessment finding indicates the presence
of this complication?
1.Flat neck veins
2.A pulse rate of 60 beats/min
3.Muffled or distant heart sounds
4.Wheezing on auscultation of the lungs
QUESTION PRACTICE
 The nurse is monitoring a client with acute
pericarditis for signs of cardiac tamponade.
Which assessment finding indicates the presence
of this complication?
1.Flat neck veins
2.A pulse rate of 60 beats/min
3.Muffled or distant heart sounds
4.Wheezing on auscultation of the lungs
3
 Assessment findings associated with cardiac
tamponade include tachycardia, distant or
muffled heart sounds, jugular vein distention
with clear lung sounds, and a falling blood
pressure accompanied by pulsus paradoxus (a
drop in inspiratory blood pressure greater than
10 mm Hg). Bradycardia is not a sign of cardiac
tamponade.
QUESTION PRACTICE
 A client admitted to the hospital with chest pain
and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which
medication would need to be withheld for 24
hours before the procedure and for 48 hours after
the procedure?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)
4
 Metformin (Glucophage) needs to be withheld 24
hours before and for 48 hours after cardiac
catheterization because of the injection of
contrast medium during the procedure. If the
contrast medium affects kidney function, with
metformin in the system, the client would be at
increased risk for lactic acidosis. The medications
in the remaining options do not need to be
withheld 24 hours before and 48 hours after
cardiac catheterization.
QUESTION PRACTICE
 A client is wearing a continuous cardiac monitor,
which begins to sound its alarm. A nurse sees no
electrocardiographic complexes on the screen.
Which is the priority action of the nurse?
1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.
4.Press the recorder button on the
electrocardiogram console.
2
 Sudden loss of electrocardiographic complexes
indicates ventricular asystole or possibly
electrode displacement. Accurate assessment of
the client and equipment is necessary to
determine the cause and identify the appropriate
intervention. The remaining options are
secondary to client assessment.
QUESTION PRACTICE
 A client is having frequent premature ventricular
contractions. The nurse should place priority on
assessment of which item?
1.Sensation of palpitations
2.Causative factors, such as caffeine
3.Precipitating factors, such as infection
4.Blood pressure and oxygen saturation
4
 Premature ventricular contractions can cause
hemodynamic compromise. Therefore, the
priority is to monitor the blood pressure and
oxygen saturation. The shortened ventricular
filling time can lead to decreased cardiac output.
The client may be asymptomatic or may feel
palpitations. Premature ventricular contractions
can be caused by cardiac disorders, states of
hypoxemia, or by any number of physiological
stressors, such as infection, illness, surgery, or
trauma, and by intake of caffeine, nicotine, or
alcohol.
QUESTION PRACTICE
 The home care nurse is providing instructions to
a client with an arterial ischemic leg ulcer about
home care management and self-care
management. Which statement, if made by the
client, indicates a need for further instruction?
1."I need to be sure not to go barefoot around the
house."
2."If I cut my toenails, I need to be sure that I cut
them straight across."
3."It is all right to apply lanolin to my feet, but I
shouldn't place it between my toes."
4."I need to be sure that I elevate my leg above
my heart level for at least an hour every day."
4
 Foot care instructions for the client with
peripheral arterial disease are the same as those
for a client with diabetes mellitus. The client
with arterial disease, however, should avoid
raising the legs above the level of the heart
unless instructed to do so as part of an exercise
program or if venous stasis is also present. The
client statements in options 1, 2, and 3 are
correct statements.
QUESTION PRACTICE
 The nurse is developing a plan of care for a client
with varicose veins in whom skin breakdown
occurred over the varicosities as a result of
secondary infection. Which is a priority
intervention?
1.Keep the legs aligned with the heart.
2.Elevate the legs higher than the heart.
3.Clean the skin with alcohol every hour.
4.Position the client onto the side every shi
2
 In the client with a venous disorder, the legs are
elevated above the level of the heart to assist
with the return of venous blood to the heart.
Alcohol is very irritating and drying to tissues
and should not be used in areas of skin
breakdown. Option 4 specifies infrequent care
intervals, so it is not the priority intervention.
QUESTION PRACTICE
 A client recovering from pulmonary edema is
preparing for discharge. What should the nurse
plan to teach the client to do to manage or
prevent recurrent symptoms after discharge?
1.Sleep with the head of bed flat.
2.Weigh himself or herself on a daily basis.
3.Take a double dose of the diuretic if peripheral
edema is noted.
4.Withhold prescribed digoxin (Lanoxin) if slight
respiratory distress occurs.
2
 The client can best determine fluid status at
home by weighing himself or herself on a daily
basis. Increases of 2 to 3 lb in a short period are
reported to the health care provider (HCP). The
client should sleep with the head of the bed
elevated. During recumbent sleep, fluid (which
has seeped into the interstitium with the
assistance of the effects of gravity) is rapidly
reabsorbed into the systemic circulation. Sleeping
with the head of the bed flat is therefore avoided.
The client does not modify medication dosages
without consulting the HCP.
QUESTION PRACTICE
 A nurse who is auscultating a 56-year-old client's
apical heart rate before administering digoxin
(Lanoxin) notes that the heart rate is 52
beats/min. The nurse should make which
interpretation about this information?
1.Normal, because of the client's age
2.Abnormal, requiring further assessment
3.Normal, as a result of the effects of digoxin
4.Normal, because this is the reason the client is
receiving digoxin
2
 The normal heart rate is 60 to 100 beats/min in
an adult. On auscultating a heart rate that is less
than 60 beats/min, the nurse would not
administer the digoxin and would report the
finding to the health care provider. Digoxin
increases the strength and contraction of the
heart; it is not used to treat low heart rates. If a
low heart rate is noted in a client taking digoxin,
the medication is withheld and the health care
provider is notified. Options 1, 3, and 4 are
incorrect interpretations because the heart rate
of 52 beats/min is not normal.
QUESTION PRACTICE
 A nurse is listening to a cardiologist explain the
results of a cardiac catheterization to a client and
family. The health care provider (HCP) tells the
client that a blockage is present in the large
blood vessel that supplies the anterior wall of the
left ventricle. The nurse determines that the
HCP is referring to which arteries?
1.Circumflex coronary artery
2.Right coronary artery (RCA)
3.Posterior descending coronary artery (PDA)
4.Left anterior descending coronary artery (LAD)
4
 The LAD bifurcates from the left main coronary
artery to supply the anterior wall of the left
ventricle and a few other structures. The
circumflex coronary artery bifurcates from the
left coronary artery and supplies the left atrium
and the lateral wall of the left ventricle. The RCA
supplies the right side of the heart, including the
right atrium and right ventricle. The PDA
supplies the posterior wall of the heart.
QUESTION PRACTICE
 A nurse is assigned to the care of a client
hospitalized with a diagnosis of hypothermia.
The nurse anticipates that the client will exhibit
which findings on assessment of vital signs?
1.Increased heart rate and increased blood
pressure
2.Increased heart rate and decreased blood
pressure
3.Decreased heart rate and increased blood
pressure
4.Decreased heart rate and decreased blood
4
 Hypothermia decreases the heart rate and the
blood pressure because the metabolic needs of the
body are reduced in this condition. With fewer
metabolic needs, the workload of the heart
decreases, resulting in decreased heart rate and
blood pressure. Therefore, options 1, 2, and 3 are
incorrect.
QUESTION PRACTICE
 A client who has had a myocardial infarction asks
the nurse why she should not bear down or strain
to ensure having a bowel movement. The nurse's
response incorporates the information that
bearing down or straining would trigger which
physical response?
1.Vagus nerve stimulation, causing a decrease in
heart rate and cardiac contractility
2.Vagus nerve stimulation, causing an increase in
heart rate and cardiac contractility
3.Sympathetic nerve stimulation, causing an
increase in heart rate and cardiac contractility
4.Sympathetic nerve stimulation, causing a
decrease in heart rate and cardiac contractility
1

Bearing down as if straining to have a bowel

movement can stimulate a vagal reflex.
Stimulation of the vagus nerve causes a decrease
in heart rate and cardiac contractility.
Stimulation of the sympathetic nervous system
has the opposite effect. These two branches of the
autonomic nervous system oppose each other to
maintain homeostasis.
QUESTION PRACTICE
 A client with iron deficiency anemia complains of
feeling fatigued almost all of the time. The nurse
should respond with which statement?
1."The work of breathing is increased when the
client is anemic."
2."Blood flows more slowly when the hemoglobin
or hematocrit is low."
3."The body has to work harder to fight infection
in the presence of anemia."
4."Adequate amounts of hemoglobin are needed
to carry oxygen for tissue metabolism."
4
 Oxygen is required to meet the metabolic needs
of the body. With decreased hemoglobin, such as
in iron deficiency anemia, the oxygen-carrying
capacity of the blood is less than normal. The
client feels the effects of this change as fatigue.
Options 1, 2, and 3 are incorrect.
QUESTION PRACTICE
 The nurse is concerned about the adequacy of
peripheral tissue perfusion in the post-cardiac
surgery client. Which action should the nurse
include within the plan of care for this client?
1.Use the knee-gatch on the bed.
2.Cover the legs lightly when sitting in a chair.
3.Encourage the client to cross legs when sitting
in a chair.
4.Provide pillows for the client to place under the
knees as desired.
2

Covering the legs with a light blanket during

sitting promotes warmth and vasodilation of the
leg vessels. The nurse plans postoperative
measures to prevent venous stasis. These include
applying elastic stockings or leg wraps, use of
pneumatic compression boots, and discouraging
leg-crossing. Clients should be encouraged to
perform passive and active range of motion
exercises. The knee gatch on the bed and pillows
under the knees should be avoided because it
places pressure on the blood vessels in the
popliteal area, impeding venous retu
QUESTION PRACTICE
 The nurse is instructing the post-cardiac surgery
client about activity limitations for the first 6
weeks after hospital discharge. The nurse should
include which item in the instructions?
1.Driving is permitted so long as the lap and
shoulder seat belts are worn.
2.Lifting should be restricted to objects that do
not weigh more than 25 pounds.
3.Use the arms for balance, not weight support,
when getting out of bed or a chair.
4.Activities that involve straining may be
resumed so long as they do not cause pain.
3

The client is taught to use the arms for balance,

but not weight support, to avoid the effects of
straining on the sternum. Typical discharge
activity instructions for the first 6 weeks include
instructing the client to lift nothing heavier than
5 pounds, to not drive, and to avoid any activities
that cause straining. These limitations are to
allow for sternal healing, which takes
approximately 6 weeks.
QUESTION PRACTICE
 A client complains of calf tenderness, and
thrombophlebitis is suspected. The nurse should
next assess the client for which finding?
1.Bilateral edema
2.Increased calf circumference
3.Diminished distal peripheral pulses
4.Coolness and pallor of the affected limb
2
 The client with thrombophlebitis, also known as
deep vein thrombosis, exhibits redness or
warmth of the affected leg, tenderness at the site,
possibly dilated veins (if superficial), low-grade
fever, edema distal to the obstruction, and
increased calf circumference in the affected
extremity. Peripheral pulses are unchanged from
baseline because this is a venous, not an arterial,
problem. Often, thrombophlebitis develops
silently; that is, the client does not present with
any signs and symptoms unless pulmonary
embolism occurs as a complication.
QUESTION PRACTICE
 The nurse is planning care for a client with deep
vein thrombosis of the right leg. Which
interventions would the nurse plan, based on the
health care provider's prescriptions? Select all
that apply.
1.Elevation of the right leg
2.Ambulation in the hall every 4 hours
3.Application of moist heat to the right leg
4.Administration of acetaminophen (Tylenol)
5.Monitoring for signs of pulmonary embolism
1345

Standard management of the client with deep

vein thrombosis includes possible bed rest for 5 to
7 days or as prescribed; limb elevation; relief of
discomfort with warm, moist heat and analgesics
as needed; anticoagulant therapy; and
monitoring for signs of pulmonary embolism.
Ambulation is contraindicated because it
increases the likelihood of dislodgement of the
tail of the thrombus, which could travel to the
lungs as a pulmonary embolism.
QUESTION PRACTICE
 A client has been diagnosed with thromboangiitis
obliterans (Buerger's disease). The nurse is
identifying measures to help the client cope with
lifestyle changes needed to control the disease
process. The nurse plans to refer the client to
which member of the health care team?
1.Dietitian
2.Medical social worker
3.Pain management clinic
4.Smoking-cessation program
4
 Buerger's disease is a vascular occlusive disease
that affects the medium and small arteries and
veins. Smoking is highly detrimental to the client
with Buerger's disease, so stopping smoking
completely is recommended. Because smoking is
a form of chemical dependency, referral to a
smoking-cessation program may be helpful for
many clients. For many clients with Buerger's
disease, symptoms are relieved or alleviated once
smoking stops. A dietitian, a medical social
worker, and a pain management clinic are not
specifically associated with the lifestyle changes
required in this disorder although they may be
needed if secondary problems arise.
QUESTION PRACTICE
 The home health nurse is visiting a client who
has had a prosthetic valve replacement for severe
mitral valve stenosis. Which statement by the
client reflects an understanding of specific
postoperative care after this surgery?
1."I need to count my pulse every day."
2."I have to do deep breathing exercises every 2
hours."
3."I threw away my straight razor and bought an
electric razor."
4."I have to go to the bathroom frequently
because of my medication."
3
 Prosthetic valves require long-term
anticoagulation to prevent clots from forming on
the "foreign" tissue implanted in the client's body.
Anticoagulation therapy requires clients to avoid
any trauma or potential means of causing
bleeding, such as the use of straight razors.
Counting pulse, deep breathing exercises, and
going to the bathroom frequently are not
specifically related to postoperative care after
prosthetic valve replacement.
QUESTION PRACTICE
 The home health nurse visits a client recovering
from cardiogenic shock secondary to an anterior
myocardial infarction and provides home care
instructions to the client. Which statement by the
client indicates an understanding of these home
care measures?
1."I exercise every day after breakfast."
2."I've gained 8 pounds since discharge."
3."I take an antacid when I experience epigastric
pain."
4."I have planned periods of rest at 10:00 am and
3:00 pm daily."
4
 The client recovering from cardiogenic shock
secondary to a myocardial infarction will require a
progressive rehabilitation related to physical activity.
The heart requires several months to heal from an
uncomplicated myocardial infarction. The
complication of cardiogenic shock increases the
recovery period for healing. Paced activities with
planned rest periods will decrease the chance of
experiencing angina or delayed healing. It is best to
allow the meal to settle prior to activity in order to
improve circulation to the heart during exercise.
Epigastric pain or a weight gain of 8 pounds is
significant and should be reported to the health care
provider, at which point follow-up should occur.
QUESTION PRACTICE
 The nurse notes that a client's cardiac rhythm
shows absent P waves and no PR interval. How
should the nurse interpret this rhythm?
1.Bradycardia
2.Tachycardia
3.Atrial fibrillation
4.Normal sinus rhythm (NSR)
3
 In atrial fibrillation, the P waves may be absent.
There is no PR interval, and the QRS duration
usually is normal and constant. Bradycardia is a
slowed heart rate, and tachycardia is a fast heart
rate. In NSR a P wave precedes each QRS
complex, the rhythm is essentially regular, the
PR interval is 0.12 to 0.20 seconds in duration,
and the QRS interval is 0.06 to 0.10 seconds in
duration.
QUESTION PRACTICE
 The nurse is teaching a client with
cardiomyopathy about home care safety
measures. The nurse should address with the
client which most important measure to ensure
client safety?
1.Assessing pain
2.Administering vasodilators
3.Avoiding over-the-counter medications
4.Moving slowly from a sitting to a standing
position
4
 Orthostatic changes can occur in the client with
cardiomyopathy as a result of venous return
obstruction. Sudden changes in blood pressure
may lead to falls. Vasodilators normally are not
prescribed for the client with cardiomyopathy.
Options 1 and 3, although important, are not
directly related to the issue of safety.
QUESTION PRACTICE
 A client with an acute respiratory infection is
admitted to the hospital with a diagnosis of sinus
tachycardia. Which nursing action should be
included in the client's plan of care?
1.Limiting oral and intravenous fluids
2.Measuring the client's pulse each shift
3.Providing the client with short, frequent walks
4.Eliminating sources of caffeine from meal trays
4
 Sinus tachycardia often is caused by fever,
physical and emotional stress, heart failure,
hypovolemia, certain medications, nicotine,
caffeine, and exercise. Fluid restriction and
exercise will not alleviate tachycardia. Option 2
will not decrease the heart rate. Additionally, the
pulse should be taken more frequently than each
shift.
QUESTION PRACTICE
 A client has developed uncontrolled atrial
fibrillation with a ventricular rate of 150
beats/min. What manifestation should the nurse
observe for when performing the client's focused
assessment?
1.Flat neck veins
2.Nausea and vomiting
3.Hypotension and dizziness
4.Clubbed fingertips and headache
3
 The client with uncontrolled atrial fibrillation
with a ventricular rate greater than 100
beats/min is at risk for low cardiac output due to
loss of atrial kick. The nurse assesses the client
for palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness,
dizziness, syncope, shortness of breath, and
distended neck veins.
QUESTION PRACTICE
 A client is admitted to the hospital with a
diagnosis of pericarditis. The nurse should assess
the client for which manifestation that
differentiates pericarditis from other
cardiopulmonary problems?
1.Anterior chest pain
2.Pericardial friction rub
3.Weakness and irritability
4.Chest pain that worsens on inspiration
2
 A pericardial friction rub is heard when
inflammation of the pericardial sac is present
during the inflammatory phase of pericarditis.
Anterior chest pain may be experienced with
angina pectoris and myocardial infarction.
Weakness and irritability are nonspecific
complaints and could accompany a wide variety
of disorders. Chest pain that worsens on
inspiration is characteristic of both pericarditis
and pleurisy.
QUESTION PRACTICE
 Cardiac monitoring leads are placed on a client
who is at risk for premature ventricular
contractions (PVCs). Which heart rhythm will the
nurse most anticipate in this client if PVCs are
occurring?
1.A P wave preceding every QRS complex
2.QRS complexes that are short and narrow
3.Inverted P waves before the QRS complexes
4.Premature beats followed by a compensatory
pause
4
 PVCs are abnormal ectopic beats originating in
the ventricles. They are characterized by an
absence of P waves, presence of wide and bizarre
QRS complexes, and a compensatory pause that
follows the ectopy.
QUESTION PRACTICE
 The nurse is performing an admission
assessment on a client with a diagnosis of
Raynaud's disease. How should the nurse assess
for this disease?
1.Checking for a rash on the digits
2.Observing for softening of the nails or nail beds
3.Palpating for a rapid or irregular peripheral
pulse
4.Palpating for diminished or absent peripheral
pulses
4
 Raynaud's disease produces closure of the small
arteries in the distal extremities in response to
cold, vibration, or external stimuli. Palpation for
diminished or absent peripheral pulses checks for
interruption of circulation. Skin changes include
hair loss, thinning or tightening of the skin, and
delayed healing of cuts or injuries. The nails grow
slowly, become brittle or deformed, and heal
poorly around the nail beds when infected.
Although palpation of peripheral pulses is
correct, a rapid or irregular pulse would not be
noted.
QUESTION PRACTICE
 The health care provider prescribes bedrest for a
client who developed deep vein thrombosis (DVT)
after surgery. What interventions should the
nurse plan to include in the client's plan of care?
Select all that apply.
1.Place in Fowler's position for eating.
2.Encourage coughing with deep breathing.
3.Encourage increased oral intake of water daily.
4.Place thigh-length elastic stockings on the
client.
5.Place sequential compression boots on the
client.
6.Encourage the intake of dark green, leafy
vegetables.
234

The client with DVT may require bedrest to prevent
embolization of the thrombus resulting from skeletal muscle
action, anticoagulation to prevent thrombus extension and
allow for thrombus autodigestion, fluids for hemodilution and
to decrease blood viscosity, and elastic stockings to reduce
peripheral edema and promote venous return. While the client
is on bedrest, the nurse prevents complications of immobility
by encouraging coughing and deep breathing. Venous return is
important to maintain because it is a contributing factor in
DVT, so the nurse maintains venous return from the lower
extremities by avoiding hip flexion, which occurs with Fowler's
position. The nurse avoids providing foods rich in vitamin K,
such as dark green, leafy vegetables, because this vitamin can
interfere with anticoagulation, thereby increasing the risk of
additional thrombi and emboli. The nurse also would not
include use of sequential compression boots for an existing
thrombus. They are used only to prevent DVT, because they
mimic skeletal muscle action and can disrupt an existing
thrombus, leading to pulmonary embolism.
QUESTION PRACTICE
 Spironolactone (Aldactone) is prescribed for a
client with heart failure. In providing dietary
instructions to the client, the nurse identifies the
need to avoid foods that are high in which
electrolyte?
1.Calcium
2.Potassium
3.Magnesium
4.Phosphorus
2
 Spironolactone (Aldactone) is a potassium-
retaining diuretic, and the client should avoid
foods high in potassium. If the client does not
avoid foods high in potassium, hyperkalemia
could develop. The client does not need to avoid
foods that contain calcium, magnesium, or
phosphorus while taking this medication.
QUESTION PRACTICE
 A client is seen in the emergency department for
complaints of chest pain that began 3 hours ago.
The nurse should suspect myocardial injury or
infarction if which laboratory value came back
elevated?
1.Myoglobin
2.Cardiac troponin
3.C-reactive protein
4.Creatine kinase (CK)
2
 Cardiac troponin elevations indicate myocardial
injury or infarction. Although the remaining
options may also rise, they are not definitive
enough to draw a conclusive diagnosis.
QUESTION PRACTICE
 The nurse is giving discharge instructions to a
client who has just undergone vein ligation and
stripping. The nurse evaluates that the client
understands activity and positioning limitations
if the client states that which action is
appropriate to do?
1.Walk for as long as possible each day.
2.Cross the legs at the ankle only, not at the
knee.
3.Lie down with the legs elevated and avoid
sitting.
4.Sit in a chair 3 times a day for 3 hours at a
time.
3

The client who has had vein ligation and

stripping should avoid standing or sitting for
prolonged periods. The client should remain lying
down unless performing a specific activity for the
first few days after the procedure. Prolonged
standing or sitting increases the risk of edema in
the legs by decreasing blood return to the heart.
The client should avoid crossing the legs at any
level for the same reason.
QUESTION PRACTICE
 A client with no history of cardiovascular disease
comes to the ambulatory clinic with flu-like
symptoms. The client suddenly complains of
chest pain. Which question should best help a
nurse discriminate pain caused by a noncardiac
problem?
1."Can you describe the pain to me?"
2."Have you ever had this pain before?"
3."Does the pain get worse when you breathe in?"
4."Can you rate the pain on a scale of 1 to 10,
with 10 being the worst?"
3

Chest pain is assessed by using the standard
pain assessment parameters (e.g.,
characteristics, location, intensity, duration,
precipitating and alleviating factors, and
associated symptoms). The remaining options
may or may not help discriminate the origin of
pain. Pain of pleuropulmonary origin usually
worsens on inspiration.
QUESTION PRACTICE
 A client with myocardial infarction has been
transferred from a coronary care unit to a general
medical unit with cardiac monitoring via
telemetry. The nurse should plan to allow for
which client activity?
1.Strict bed rest for 24 hours after transfer
2.Bathroom privileges and self-care activities
3.Ad lib activities because the client is monitored
4.Unsupervised hallway ambulation with
distances under 200 feet
2
 On transfer from the coronary care unit, the
client is allowed self-care activities and bathroom
privileges. Strict bedrest is unnecessary and can
be harmful and promote emboli. Supervised
ambulation in the hall for brief distances is
encouraged, with distances gradually increased
(50, 100, 200 feet).
QUESTION PRACTICE
 A client with pulmonary edema has been
receiving diuretic therapy. The client has a
prescription for additional furosemide (Lasix) in
the amount of 40 mg intravenous push. Knowing
that the client will also be started on digoxin
(Lanoxin), which laboratory result should the
nurse review as the priority?
1.Sodium level
2.Digoxin level
3.Creatinine level
4.Potassium level
4
 The serum potassium level is measured in the
client receiving digoxin and furosemide.
Heightened digoxin effect leading to digoxin
toxicity can occur in the client with hypokalemia.
Hypokalemia also predisposes the client to
ventricular dysrhythmias.
QUESTION PRACTICE
 A nurse is caring for a client with unstable
ventricular tachycardia. The nurse should
instruct the client to take which action, if
prescribed, during an episode of ventricular
tachycardia?
1.Lie down flat in bed.
2.Remove any metal jewelry.
3.Breathe deeply, regularly, and easily.
4.Inhale deeply and cough forcefully every 1 to 3
seconds.
4
 Restorative coughing techniques are sometimes
used in the client with unstable ventricular
tachycardia. The nurse tells the client to use
cough cardiopulmonary resuscitation (CPR), if
prescribed, by inhaling deeply and coughing
forcefully every 1 to 3 seconds. Cough CPR may
terminate the dysrhythmia or sustain the
cerebral and coronary circulation for a short time
until other measures can be implemented. The
other options will not assist in terminating the
dysrhythmia.