Cardiovascular Practice Answers and Rationales
1) Correct answer: C
a. INR is the value used to assess effectiveness of the warfarin sodium
therapy. INR is the prothrombin time ratio that would be obtained if the
thromboplastin reagent from the World Health Organization was used for
the plasma test. It is now the recommended method to monitor
effectiveness of warfarin sodium. Generally, the INR for clients
administered warfarin sodium should range from 2 to 3. In the past,
prothrombin time was used to assess effectiveness of warfarin sodium
and was maintained at 1.5 to 2.5 times the control value. Partial
thromboplastin time is used to assess the effectiveness of heparin
therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin
sodium anticoagulant effect, whereas protamine sulfate reverses the
effects of heparin. Warfarin sodium will help to prevent blood clots.
2) Correct answer: C
a. (A) The therapeutic range for INR is 2 to 3; therefore, this client would not
need to be contacted first. (B) The client’s serum potassium level is within
the normal range—3.5 to 5.5 mEq/L. Therefore, this client would not need
to be contacted first. (C) The client’s digoxin level is higher than the
therapeutic level for digoxin, which is 0.8 to 2 mg/dL. This client should be
contacted first to assess for signs/ symptoms of digoxin toxicity. (D) The
glycosylated hemoglobin, which is the average of blood glucose levels
over 3 months, should not be more than 8%. This client, with a level of
6%, does not need to be contacted.
3) Correct answer: C
a. (A) The cardiac glycoside, such as digoxin, should not be administered
unless the apical pulse is 60 or above. (B) Because the client’s serum K+
level is already low, the nurse should question administering a loop
diuretic. (C) The client in ventricular fibrillation is in a life-threatening
situation; therefore, the antidysrhythmic, such as lidocaine or amiodarone,
should be administered first. (D) The client’s blood pressure is above
90/60, so the calcium-channel blocker can be administered but it is not
priority over a client who is in a life-threatening situation.
4) Correct answer: D
a. (A) The nurse would expect the client with a deep vein thrombosis to have
an edematous right calf, so the nurse would not need to assess this client
first. (B) The nurse would expect the client with varicose veins to have
dull, achy pain in their legs. (C) The nurse would expect the client with
peripheral artery disease to have intermittent claudication (leg pain), so
the nurse would not need to assess this client first. (D) The client would
not expect the client with congestive heart failure to have pink, frothy
sputum because this is a sign of pulmonary edema. This client should be
assessed first.
5) Correct answer: B
a. (A) The INR is not at a therapeutic level yet; the nurse should administer
this medication. (B) This potassium level is very low. Hypokalemia
potentiates dysrhythmias in clients receiving digoxin. This nurse should
discuss potassium replacement with the HCP before administering this
medication. (C) An aspartate aminotransferase (AST) test measures the
amount of this enzyme in the blood. The enzyme is part of the liver
function panel. The normal is 14–20 U/L for males and 10–36 U/L for
females. (D) Creatinine level is reflective of renal status. Normal is 0.6–1.2
mg d/L.
6) Correct answer: C
a. (A) Lasix should be administered to the client who has an adequate
urinary output. (B) Lovenox is prescribed to prevent deep vein thromboses
(DVT) in clients who are immobile, such as a postsurgical client. (C) The
nurse should not administer an antiplatelet medication to a client going to
surgery because this will increase postoperative bleeding. The nurse
should hold this medication and discuss this with the surgeon. (D) The
client’s blood pressure is within an acceptable range. The nurse should
administer this medication.
7) Correct answer: C
a. Arterial ulcers have a pale deep base and are surrounded by tissue that is
cool with trophic changes such as dry skin and loss of hair. Arterial ulcers
are caused by tissue ischemia from inadequate arterial supply of oxygen
and nutrients. A stage 1 ulcer indicates a reddened area with an intact
skin surface. A venous stasis ulcer (vascular) has a dark red base and is
surrounded by brown skin with local edema. This type of ulcer is caused
by the accumulation of waste products of metabolism that are not cleared,
as a result of venous congestion.
8) Correct answer: B
a. 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.
9) Correct answer: C
a. Cilostazol is indicated for management of intermittent claudication.
Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent
cortication prevents clients from walking for long periods of time.
Cilostazol inhibits platelet aggregation induced by various stimuli and
improving blood flow to the muscles and allowing the client to walk long
distances without pain. Peripheral artery disease causes pain mostly of
the leg muscles. “aches and pains” does not specify exactly where the
pain is occurring. Headaches may occur as a side effect of this drug, and
the client should report this information to the HCP. Peripheral artery
disease causes decreased blood supply to the peripheral tissues and may
cause gangrene of the toes; the drug is effective when toes are warm to
the touch and the color of the toes are similar to the color of the body
10) Correct answers: B, D
a. Reduction of blood flow to a specific area results in decreased oxygen and
nutrients. As a result, the skin may appear mottled. This skin will also be
cool to touch. Loss of hair and dry skin or other signs the nurse may
observe in a client with peripheral arterial disease of the lower extremities.
11) Correct answer: D
a. Coldness in the left foot and ankle is consistent with complete arterial
obstruction. Other expected findings would include paralysis and pallor.
Aching pain, a burning sensation, or numbness and tingling are early
signs of tissue hypoxia and ischemia and are commonly associated with in
complete obstruction.
12) Correct answer: C
a. The term gangrene refers to blackened, decomposing tissue that is devoid
of circulation. Chronic ischemia and death of the tissue can lead to
gangrene in the affected extremity. Injury, edema, decreased circulation
lead to infection, gangrene and tissue death. Atrophy is this shrinking of
tissue, and contraction is joint stiffening secondary to disuse. The term
rubor denotes a reddish color of the skin.
13) Correct answer: D
a. The client should avoid using iodine or over-the-counter medications.
Iodine is a highly toxic solution. An individual who has known PVD should
be seen by an HCP for treatment to avoid infection. The client with PVD
should avoid heating pads and crossing the legs, and should wear wellfitted shoes. The heating pad can cause injury, which, because of the
decreased blood supply can be difficult to heal. Crossing the legs can
further impede blood flow. Leather shoes provide better protection.
14) Correct answer: C
a. Nicotine causes vasospasm and impedes bloodflow. Stopping smoking is
the most significant lifestyle change the client can make. The client should
eat low fat foods as part of a balanced diet. The legs should not be
elevated above the heart because this will impede arterial flow. The legs
should be in a slightly dependent position. Jogging is not necessary and
probably is not possible for many clients with arterial occlusive disease. A
rehabilitation program include daily walking is suggested.
15) Correct answer: B
a. Performing active ankle and foot range of motion exercises periodically
during the ride home and will provide muscular contraction it provides
support to the venous system. It is the muscular action that facilitates
return of the blood from the lower extremities, especially when in the
dependent position. Arm circle exercises will not promote circulation in the
legs. It is not necessary for the client to elevate the legs as long as the
client does not include blood flow to the legs and does leg exercises. It is
not necessary to taking ambulance because the client is able to sit in a car
safely.
16) Correct answer: C
a. Secondary varicosities can result from previous thrombophlebitis of the
deep moral veins with subsequent valvular incompetence.
Cerebrovascular accidents, anemia, and transient ischemic attacks are
not associated with increased risk of varicose veins.
17) Correct answer: A
a. Sclerotherapy involves injecting small and medium-sized varicose veins
with a solution that scars encloses those friends. In a few weeks, the vein
should faded disappear. This procedure does not require anesthesia and
can be done in HCP’s office. Varicose veins can reoccur regardless of the
procedure. Bruising is more likely following vein stripping or catheter
associated procedures.
18) Correct answer: D
a. 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 the remaining
options are correct statements, and indicate that the teaching has been
effective.
19) Correct answers: B, D, E
a. Long-term management of peripheral arterial disease consists of
measures that increase peripheral circulation (exercise), promote
vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care
and nutrition). Soaking the feet in hot water and application of a heating
pad to the extremity are contraindicated. The affected extremity may have
decreased sensitivity and is at risk for burns. Also, the affected tissue
does not obtain adequate circulation at rest. Direct application of heat
raises oxygen and nutritional requirements of the tissue even further.
20) Correct answer: D
a. Acute arterial insufficiency is associated with interruption of arterial blood
flow to an organ, tissue, or extremity. It is associated with an acutely
painful pasty-colored leg. The priority is for the nurse to perform a
comprehensive assessment of peripheral circulation. When pulses are
difficult to palpate, the Doppler device is useful to determine the presence
of blood flow to the area. The Doppler directs sound waves toward the
artery being examined, which emits an audible sound. The nurse must
document that the pulse was present via Doppler and not palpation.
Although the remaining options may be components of the assessment,
they are not the priority.
21) Correct answer: B
a. (A)Intermittent claudication is a symptom of arterial occlusive disease;
therefore, this client does not need to be assessed first. (B)The client with
calf pain could be experiencing deep vein thrombosis (DVT), a
complication of immobility, which may be fatal if a pulmonary embolus
occurs; therefore, this client should be assessed first. (C) The client
experiencing low back pain when sitting in a chair should be assessed but
not prior to the client with suspected DVT. (D) The nurse should address
the client’s concern about the food, but it is not priority over a physiological
problem.
22) Correct answer: B
a. (A) This would not warrant immediate intervention because intermittent
claudication, pain when walking, is the hallmark sign of arterial occlusive
disease. (B) This comment warrants immediate intervention because the
client’s legs have decreased sensation secondary to the arterial occlusive
disease, and a heating pad could burn the client’s legs without the client’s
realizing it. The client should not use a heating pad to keep the legs warm.
(C) Hanging his or her legs off the bed helps increase the arterial blood
supply to the legs, which, in turn, helps decrease the leg pain. This
comment would not warrant immediate intervention by the nurse. (D) Hair
growth requires oxygen, and the client has decreased oxygen to the legs;
therefore, decreased hair growth would be expected and not require
immediate intervention.
23) Correct answer: C
a. (A) Increased hair loss occurs due to decreased oxygen to the lower
extremities, but this is not life threatening; therefore, this information would
not warrant immediate intervention. (B) The client with arterial occlusive
disease would be expected to have an 1+ dorsalis pedal pulse; therefore,
this would not warrant immediate intervention. (C) Numbness, tingling,
and inability to move his or her toes would warrant intervention by the
nurse. This indicates no arterial blood flow to the extremities. (D) The
client hangs his or her legs off the bed to help increase arterial oxygen
blood flow to the lower extremities. This would not warrant immediate
intervention.
24) Correct answer: C
a. Keeping the involved extremity dangling will facilitate tissue perfusion and
prevent tissue damage. The nurse should avoid placing the affected
extremity on a hard surface, such as a firm mattress, to avoid pressure
ulcers. In addition, the involved extremity should be free from heavy
overlying bed linens. The nurse should handle the involved extremity in a
gentle fashion to prevent friction or pressure, raising the leg would cause a
occlusion to the iliac artery, which is contrary to the goal to promote the
arterial circulation.
25) Correct answer: D
a. And ankle brachial index of 0.65 suggests moderate arterial vascular
disease in a client who is experiencing intermittent claudication. A Doppler
ultrasound is indicated for further evaluation. The bradycardic heart rate is
acceptable in an athletic client with a normal blood pressure. The SpO2
two is acceptable; the client has a smoking history.
26) Correct answer: A
a. Venous stasis can cause increased pain. Therefore, proper positioning in
bed with a foot of the bed elevated or when sitting up in a chair can help
promote venous drainage, reduce swelling, and reduced the amount of
pain the client might experience. Placing a pillow under the knees causes
flexion of the joint, resulting in a deep end position of the lower lag and
causing a decrease in blood flow. Fluids are in courage to maintain normal
fluid electrolyte balance but do little to relieve pain. Therapeutic massage
to the legs is discouraged because of the danger of breaking up the clot.
27) Correct answer: C
a. The first action should be to discontinue the IV. The nurse should restart
the IV elsewhere and then apply a warm compress to the affected area.
The nurse should administer acetaminophen or an oral anti-inflammatory
agent only if prescribed by the HCP. The type of infusion cannot be
change without an HCP’s prescription and such a change would not help
in this case.
28) Correct answers: A, B, D
a. To manage varicose veins, the nurse should coach the client to lose
weight to relieve pressure on the veins, wear compression stockings to
promote circulation, and elevate the legs when sitting or lying down.
Applying lotion to the veins will keep the skin moist, but does not promote
venous circulation. Pillows under the knees will obstruct circulation.
29) Correct answer: A
a. Before starting a heparin infusion, it is the essential for the nurse to know
that clients baseline coagulation values (hematocrit, hemoglobin, and red
blood cell and platelets counts). In addition, the partial thromboplastin
time should be monitored closely during the process. The client stools
would be tested only if internal bleeding what’s suspect. Although
monitoring vital signs are important in assessing potential sites and
symptoms of hemorrhage or potential adverse reactions to the medication,
vital signs are not the most important data to collect before administering
the heparin. Intake and output are not important assessments for heparin
administration unless the client has fluid and volume problems of kidney
disease.
30) Correct answer: B
a. (A) The nurse should document the results in the client’s chart, but this is
not the nurse’s first intervention. (B) The therapeutic value for INR is 2 to
3; levels higher than that increase the risk of bleeding. The nurse should
first contact the client and determine whether she has any abnormal
bleeding and then instruct the client to not take any more Coumadin. (C)
The nurse should notify the client’s HCP, but the nurse should first
determine whether the client has any abnormal bleeding so that can be
reported to the HCP. (D) The client will need to have another INR drawn,
but it is not the nurse’s first intervention.
31) Correct answer: B
a. With each set of vital signs, the nurse should assess the dorsalis pedis
and posterior tibial pulses. The nurse needs to ensure adequate perfusion
to the lower extremity with the drop in blood pressure. IV fluids, nasal
cannula setting, and capillary refill are important to assess; however,
priority is to determine the cause of drop in blood pressure and that
adequate perfusion through the new graft is maintained.
32) Correct answer: C
a. When pedal pulses are not palpable, the nurse should obtain a Doppler
ultrasound device. Auscultation is not likely to be helpful if the pulse is not
palpable. Inspection of the lower extremity can’t be done simultaneously
when palpating, but the nurse should first try to locate a pulse by Doppler.
Calling the HCP may be necessary if there is a change in the clients
condition.
33) Correct answer: A
a. A Client with deep vein thrombosis is at a high risk for pulmonary
embolism from an embolus traveling to the lungs. Sudden onset of
symptoms and worsening of chest pain with a deep breath suggests a
pulmonary embolism. The nurse assesses the client and obtained oxygen
saturation levels prior to calling the HCP in administering morphine.
Range of motion is a preventative measure for DVT and is not appropriate
at this time.
34) Correct answer: C
a. The client is experiencing a rebound tachycardia from abrupt withdrawal of
the beta blocker. The beta blocker should be restarted due to the
tachycardia, history of hypertension, and the desire to reduce the risk of
post operative myocardial morbidity. The bypass surgery should correct
the claudication and need for pentoxifylline. The furosemide and increase
in fluids are not indicated since the client’s urine output and blood
pressure are satisfactory and there is no indication of bleeding. The nurse
should also determine the potassium level before restarting the
furosemide.
35) Correct answer: B
a. Slow, steady walking is a recommended activity for clients with peripheral
vascular disease because it stimulates the development of collateral
circulation. The client with PVD should not remain inactive. Elevating the
legs above the heart or wearing antiembolism stockings is a strategy for
alleviating venous congestion and may worsen peripheral arterial disease.
36) Correct answers: A, B, E
a. Turning frequently promote circulation, while using pillows for support will
prevent stress to the suture line. Short periods of different leg/body
positions will not impair post-operative oxygen levels. The client should
only be in the knee flexed position when walking and not at rest.
Prolonged sitting is discouraged, and it may cause pain and edema. It is
not recommended but the leg to be placed and a dependent position
because this promotes edema. Placing the client in a supine position with
the leg elevated above the heart is recommended only if the client
develops edema.
37) Correct answer: D
a. According to laboratory findings, prothrombin time and INR are at an
acceptable anticoagulation level for the treatment of DVT. However, the
platelets are below the acceptable level. Clients taking enoxaparin are at
risk for thrombocytopenia. Because of the low platelet level, the nurse
should withhold the enoxaparin in contact HCP. The nurse should not
administer the drug until the HCP has been contacted. The HCP, not a
pharmacist, will make the decision about the dose of the drug. The
decision about administering the drug will be made based on laboratory
values, not evidence of bruising or bleeding.
38) Correct answer: B
a. Acute arterial occlusion is a sudden interruption of blood flow. The
interruption can be the result of complete or partial obstruction. Acute
pain, loss of sensory and motor function, and a pale, mottled, numb
extremity are the most romantic and observable changes that indicate a
life-threatening interruption tissue perfusion. Blood-pressure and heart
rate changes may be associated with the acute pain episodes. Metabolic
acidosis is a complication of irreversible ischemia. The Swelling may result
but may also indicate venous stasis or arterial insufficiency.
39) Correct answer: A
a. The client with heart failure may present with different symptoms,
depending on whether the right or the left side of the heart is failing.
Peripheral and sacral edema, jugular vein distention, and organomegaly
all are manifestations of problems with right-sided heart function. Lung
sounds constitute an accurate indicator of left-sided heart function.
40) Correct answer: B
a. Spironolactone 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.
41) Correct answer: C
a. The client with heart failure may present with different symptoms,
depending on whether the right side or the left side of the heart is failing.
Adventitious breath sounds, such as crackles, are an indicator of
decreased left-sided heart function. Peripheral edema, jugular vein
distention, and ascites all can be present because of insufficiency of the
pumping action of the right side of the heart.
42) Correct answer: C
a. Warfarin is an anticoagulant, which is used in the treatment is atrial
fibrillation and decreased left ventricular ejection fraction (<20%) to
prevent thrombus formation and release of emboli into the circulation. The
client may also take other medication as needed to manage the heart
failure. Warfarin does not reduce circulatory load or improve myocardial
workload. Warfarin does not affect cardiac rhythm.
43) Correct answer: C
a. Sitting almost upright in bed with the feet and legs resting on the mattress
decreases venous return to the heart, thus reducing myocardial workload.
Also, the sitting position allows maximum space for lung expansion. Low
Fowler’s position would be used if the client could not tolerate high
Fowler’s position for some reason. Lying on the right side would not be a
good position for the client in heart failure. The client in heart failure would
not tolerate Trendelenburg’s position.
44) Correct answer: B
a. Digoxin is a cardiac glycoside with positive inotropic activity. This
inotropic activity causes increased strength of myocardial contractions and
thereby increases output of blood from the left ventricle. Digoxin does not
dilate coronary arteries. Although digoxin can be used to treat
arrhythmias and odes decrease the electrical conductivity of the
myocardium, these are not primary reasons for its use in clients with heart
failure and pulmonary edema.
45) Correct answer: D
a. When diuretics are given early in the day, the client will void frequently
during the daytime hours and will not need to void frequently during the
night. Therefore, the client’s sleep will not be disturbed. Taking
furosemide in the morning has no effect on preventing electrolyte
imbalances or retarding rapid drug absorption. The client should not
accumulate excessive fluids throughout the night.
46) Correct answer: C
a. Colored vision and seeing yellow spots are symptoms of digoxin toxicity.
Abdominal pain, anorexia, nausea, and vomiting are other common
symptoms of digoxin toxicity. Additional signs of toxicity include
arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased
appetite, and elevated blood pressure are not associated with digoxin
toxicity.
47) Correct answer: D
a. A low serum potassium level (hypokalemia) predisposes a client to digoxin
toxicity. Because potassium inhibits cardiac excitability, a low serum
potassium level would mean that the client would be prone to increased
cardiac excitability. Sodium, glucose, and calcium levels do not affect
digoxin or contribute to digoxin toxicity.
48) Correct answer: B
a. Canned foods or juices such as tomato juice are typically high in sodium
and should be avoided in a sodium-restricted diet. Canned foods and
juices in which sodium has been removed or limited are available. The
client should be taught to read labels carefully. Apples and whole wheat
breads are not high in sodium. Beef tenderloin would have less sodium
than canned foods or tomato juice.
49) Correct answers: B, C, D
a. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and
oranges are examples of foods high in potassium. Angel food cake and
peppers are low in potassium.
50) Correct answer: B
a. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting.
Visual disturbances can also occur including double or blurred vision and
visual halos. Hypokalemia is a common cause of digoxin toxicity
associated with arrhythmias because low serum potassium can enhance
ectopic pacemaker activity. Although vomiting can lead to fluid deficit
given the patient’s history, the vomiting is more likely due to the adverse
effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea
and coughing.
51) Correct answers: D, E
a. Signs of pulmonary edema are identical to those of acute heart failure.
Signs and symptoms are generally apparent in the respiratory system and
include coarse crackles, severe dyspnea, and tachypnea. Severe
tachycardia occurs due to sympathetic stimulation in the presence of
hypoxemia. Blood pressure may decrease or be elevated, depending on
the severity of the edema. Jugular vein distention, dependent edema, and
anorexia are symptoms of right-sided heart failure.
52) Correct answer: A
a. Increasing cardiac output is the main goal of therapy for the client with
heart failure or pulmonary edema. Pulmonary edema is an acute medical
emergency requiring immediate intervention. Improved exercise tolerance
and comfort will be improved when cardiac output increases to an
acceptable level. Peripheral edema is not typically associated with
pulmonary edema.
53) Correct answer: C
a. Heart failure is a complex and chronic condition. Education should focus
on health promotion and preventative care in the home environment.
Signs and symptoms can be monitored by the client. Instructing the client
to obtain daily weights at the same time each day is very important. The
client should be told to call their HCP if there has been a weight gain of 2
lbs or more. This may indicate fluid overload, and treatment can be
prescribed early, on an outpatient basis, rather than waiting until the
symptoms become life-threatening. Following a high-fiber diet is
beneficial, but is not relevant to the teaching needs of a client with heart
failure. Prescribing an exercise program for the client such as walking 2
miles every day, would not be appropriate at discharge. The client
exercise program would need to be planned in consultation with the HCP
and based on the history and physical condition of the client. The client
may require exercise tolerance testing before an exercise plan is laid out.
Although the nurse does not prescribe an exercise program for the client,
a sedentary lifestyle should not be recommended.
54) Correct answers, A, B, D
a. If the client will call the healthcare provider (HCP) when there is increasing
shortness of breath, weight gain over 2 lbs in one day, and the need to
sleep sitting up, this indicates an understanding of teaching because these
signs and symptoms suggest worsening of client’s heart failure. Although
the client will most likely be placed on a sodium restricted diet, the client
would not need to notify the HCP if he or she consumed a high-sodium
breakfast. Instead the client would need to be alert for possible signs and
symptoms of worsening heart failure and work to reduce sodium intake for
the rest of that day and in the future.
55) Correct answers: A, B, D, E
a. (A) A 2-lb weight gain indicates the client is retaining fluid and should
contact the HCP. This is an appropriate teaching intervention. (B) Keeping
the head of the bed elevated will help the client breathe easier; therefore,
this is an appropriate teaching intervention. (C) The loop diuretic should
be taken in the morning to prevent nocturia. This is not an appropriate
teaching intervention. (D) Sodium retains water. Telling the client to avoid
eating foods high in sodium is an appropriate teaching intervention. (E)
Isotonic exercise, such as walking or swimming, helps tone the muscles,
and discussing this with the client is an appropriate teaching intervention.
56) Correct answer: C
a. The normal heart rate is 60 to 100 beats/minute in an adult. If the nurse
notes a heart rate that is less than 60 beats/minute, the nurse would not
administer the digoxin and would further evaluate the client for signs and
symptoms of digoxin toxicity. When clients are bradycardic, they may have
symptoms of decreased cardiac output, so this would also be assessed.
57) Correct answer: C
a. The nurse should withhold the dose of captopril; captopril is an ACE
inhibitor, and a side effect of the medication is hyperkalemia. The BUN
and creatinine, which are normal, should be viewed prior to administration
since renal insufficiency is another potential side effect of an ACE
inhibitor. The heart rate is within normal limits. The nurse should question
the dose of metoprolol if the client’s heart rate is bradycardic. The
hemoglobin and hematocrit are normal for a female. The nurse should
report the high potassium level and that the captopril was withheld.
58) Correct answer: A
a. The ankle edema suggests fluid volume overload. The nurse should
assess respiratory rate, lung sounds, and SPO2 to identify any signs of
respiratory symptoms of heart failure requiring immediate attention. The
nurse can then draw blood for laboratory studies, insert the foley catheter,
and weight the client.
59) Correct answer: B
a. The client has gained 5 lb in 3 days with a steady increase in blood
pressure. The client is exhibiting signs of heart failure, and if the client is
short of breath, this will be another sign. Asking how the client is feeling is
too general, and a more focused question will quickly determine the
client’s current health status. The scales should be calibrated periodically,
but a 5-lb weight gain, along with increased blood pressure, is not likely
due to problems with the scale. The weight gain is likely due to fluid
retention, not drinking too much fluid.
60) Correct answer: C
a. The sodium level can increase with the use of several types of products,
including toothpaste and mouthwash; over-the-counter medications such
as analgesics, antacids, laxatives, and sedatives; and softened water and
mineral water. Clients are instructed to read labels for sodium content.
Water that is bottled, distilled, deionized, or demineralized may be used
for drinking and cooking. Fresh fruits and vegetables are low in sodium.
61) Correct answer: C
a. Cardiac troponin T or cardiac troponin I have been found to be a protein
marker in the detection of myocardial infarction, and assay for this protein
is used in some institutions to aid in the diagnosis of a myocardial
infarction. The test is not used to diagnose heart failure, ventricular
tachycardia, or atrial fibrillation.
62) Correct answer: B
a. The client with coronary artery disease should avoid foods high in
saturated fat and cholesterol such as eggs, whole milk, and red meat.
These foods contribute to increases in low-density lipoproteins. The use of
polyunsaturated oils is recommended to control hypercholesterolemia. It is
not necessary to eliminate all cholesterol and fat from the diet. It is not
necessary to become a strict vegetarian.
63) Correct answer: C
a. The client should wear loose, comfortable clothing for the procedure.
Electrocardiogram (ECG) lead placement is enhanced if the client wears a
shirt that buttons in the front. The client should receive nothing by mouth
after bedtime or for a minimum of 2 hours before the test. The client
should wear rubber-soled, supportive shoes, such as athletic training
shoes. The client should avoid smoking, alcohol, and caffeine on the day
of the test. Inadequate or incorrect preparation can interfere with the test,
with the potential for a false-positive result.
64) Correct answer: C
a. Triamterene is a potassium-retaining diuretic, so the client should avoid
foods high in potassium. Fruits that are naturally higher in potassium
include avocados, bananas, fresh oranges, mangos, nectarines, papayas,
and prunes.
65) Correct answer: A
a. Nitroglycerin acts to decrease myocardial oxygen consumption.
Vasodilation makes it easier for the heart to eject blood, resulting in
decreased oxygen needs. Decreased oxygen demand reduces pain
caused by heart muscle not receiving sufficient oxygen. While blood
pressure may decrease due to the vasodilation effects of nitroglycerin, it is
only secondary and not related to the angina the client is experiencing.
Increased blood pressure would mean the heart would work harder,
increasing oxygen demand and thus angina. Decreased heart rate is not
an effect of nitroglycerin.
66) Correct answer: C
a. Pasta, tomato sauce, salad, and coffee would be the best selection for this
client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and
fried foods tend to be high in cholesterol.
67) Correct answer: B
a. Cardiac catherization is done in clients with angina primarily to assess the
extent and the severity of the coronary artery blockage. A decision about
medical management, angioplasty, or coronary artery bypass surgery will
be based on the catherization results. Coronary bypass surgery would be
used to bypass obstructed vessels. Although cardiac catheterization can
be used to assess the functional adequacy of valves and heart muscle, in
this case the client has unstable angina and therefore would need the
procedure to assess the extent of arterial blockage.
68) Correct answer: A
a. The effect of a beta-blocker is a decrease in heart rate, contractility, and
afterload, which leads to a decreased in blood pressure. The client at first
may have an increase in fatigue when starting the beta-blocker. The
mechanism of action does not improve blood sugar or urine output.
69) Correct answers: A, C, E
a. Clonidine is a central-acting adrenergic antagonist. It reduces
sympathetic output from the central nervous system. Dry mouth,
impotence, and sleep disturbances are possible side effects.
Hyperkalemia and pancreatitis are not anticipated with use of this drug.
70) Correct answer: A
a. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol
including reducing heart rate, decreasing myocardial contractility, and
slowing conduction. Propranolol does not increase norepinephrine
secretion, cause vasodilation, or block conversion of angiotensin I to
angiotensin II.
71) Correct answer: C
a. 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.
72) Correct answer: A
a. Obesity and sodium intake are modifiable risk factors for hypertension.
These are of the utmost importance because they can be changed or
modified by the individual through a regular exercise program and careful
monitoring of sodium intake. Protein intake has no relationship to
hypertension.
73) Correct answer: B
a. To best monitor that the client’s circulation remains intact, the dorsal
surface of the right foot should be palpated. When the left side of the
heart is catheterized, the cannula enters via an artery. In this instance,
the right femoral artery was accessed. While all options assess arterial
points of the right leg, the dorsal surface of the right foot (the pedal pulse)
is the most distal. If this pulse point is present and unchanged from before
the procedure, the other pulse points should also be intact.
74) Correct answer: A
a. The client is having symptoms of a myocardial infarction. The first action
is to prevent platelet formation and block prostaglandin synthesis. The
client should place the tablet under the tongue and wait until it is
absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or
placed between the cheek and gums.
75) Correct answers: A, C, D
a. Clopidogrel is generall well-absorbed and may be taken with or without
food; it should be taken at the same time every day, and, while food may
help prevent potential GI upset, food has no effect on absorption of the
drug. Bleeding is the most common adverse effect of clopidogrel; the
client must understand the importance of reporting any unexpected,
prolonged, or excessive bleeding including blood in urine or stool.
Increased bruising and bleeding gums are possible side effects of
clopidogrel; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have
experienced or are at risk for myocardial infarction, ischemic stroke,
peripheral artery disease, or acute coronary syndrome. It is not necessary
to drink a glass of water after taking clopidogrel.
76) Correct answer: C
a. Nitroglycerin can be taken prophylactically before stressful physical
activities such as stair climbing to help the client remain pain free.
Climbing the stairs early in the day would have no impact on decreasing
pain episodes. Resting before or after an activity is not as likely to help
prevent an activity-related pain episode.
77) Correct answer: C
a. The client taking nifedipine should inspect the gums daily to monitor for
gingival hyperplasia. This is an uncommon adverse effect but one that
required monitoring and intervention if it occurs. The client taking
nifedipine might be taught to monitor blood pressure, but more often than
monthly. These clients would not generally need to perform daily weights
or limit intake of green leafy vegetables.
78) Correct answers: B, E, F
a. Simvastatin is used in combination with diet and exercise to decrease
elevated total cholesterol. The client should take simvastatin in the
evening, and the nurse should instruct the client that if a dose is missed,
to take it as soon as remembered, but not to take at the same time as the
next scheduled dose. It is not necessary to take the pill with food. The
client does not need to limit greens (limiting greens is appropriate for client
taking warfarin), but the nurse should instruct the client to avoid grapefruit
and grapefruit juice, which can increase the amount of drug in the
bloodstream. A serious side effect is myopathy, and the client should
report muscle pain or tenderness to the HCP.
79) Correct answer: B
a. There was a significant change in both blood pressure and heart rate with
position change. This indicates inadequate blood volume to sustain
normal values. Normal postural changes allow for an increase in heart
rate of 5 to 20 bpm, a possible slight decrease of <5 mm Hg in the systolic
BP and a possible slight increase of <5 mm in the diastolic BP.
80) Correct answer: A
a. Furosemide is a diuretic often prescribed for clients with hypertension or
heart failure; the drug should not affect a client’s ability to drive safely.
Furosemide may cause orthostatic hypotension, and clients should be
instructed to be careful when changing from supine to sitting to standing
position. Diuretics should be taken in the morning if possible to prevent
sleep disturbances due to the need to get up to void. Furosemide is a
loop diuretic that is not potassium sparing; clients should take potassium
supplements as prescribed and have their serum potassium levels
checked at prescribed intervals.
81) Correct answer: B, C
a. Changing positions slowly and avoiding long periods of standing may limit
the occurrence of orthostatic hypotension. Scheduling regular medication
times is important for blood pressure management, but this aspect is not
related to the development of orthostatic hypotension. Excessive alcohol
intake and hot baths are associated with vasodilation.
82) Correct answer: A
a. Atenolol is a beta-adrenergic antagonist indicated for management of
hypertension. Sudden discontinuation of this drug is dangerous because
it may exacerbate symptoms. The medication should not be discontinued
without a prescription. Blood pressure needs to be monitored more
frequently than annually in a client that is newly diagnosed and treated for
hypertension. Clients are not usually placed on a low protein diet for
hypertension.
83) Correct answer: C
a. Processed and cured meat products, such as cold cuts, ham, and hot
dogs, are all high in both fat and sodium and should be avoided on a lowcalorie, low-fat, low salt diet. Dietary restrictions of all types are complex
and difficult to implement with clients who are basically symptomatic.
84) Correct answers: A, B, E
a. Metoprolol is a beta-adrenergic blocker indicated for hypertension, angina,
and myocardial infarction. The tablets should be taken with food at the
same time each day; they should not be chewed or crushed. The HCP
should be notified if the pulse falls below 50 for several days. Use of any
OTC decongestants and cold remedies or herbal preparations must be
avoided due to drug interactions. Fainting spells may occur due to
exercise or stress, and the dosage of the drug may need to be reduced or
discontinued.
85) Correct answers: A, B, C, E
a. Chlorothiazide causes increased urination and decreased swelling (if there
is edema) and weight loss. Clients should not drink alcoholic beverages
or take other medications without the approval of the healthcare provider.
Reducing sodium intake in the diet helps diuretic drugs to be effective and
allows smaller doses to be taken. Smaller doses are less likely to cause
adverse effects, and therefore, excessive table salt as well as salty foods
should be avoided. Chlorothiazide is a diuretic that is prescribed for lower
blood pressure and may cause dizziness and faintness when the client
stands up suddenly. This can be prevented or decrease by changing
positions slowly. If dizziness is severe, the HCP must be notified.
Diuretics may cause sensitivity to sunlight; hence the need to avoid
prolonged exposure to sunlight, use sunscreens, and wear protective
clothing. Chlorothiazide causes increased urination and must be taken
early in the day to decrease nighttime trips to the bathroom. Fewer
bathroom trips means less interference with sleep and less risk of falls.
The client should not change the dosage without consulting the HCP.
86) Correct answer: A
a. Further assessment is needed in this situation. It is premature to initiate
other actions until further data has been gathered. Inquiring about the
onset, duration, location, severity, and precipitating factors of the chest
heaviness will provide pertinent information to convey to the HCP.
References
Practice questions obtained from
Billings, D. M., & Hensel, D. (2017). Lippincott Q & A review for NCLEX-RN.
Philadelphia: Wolters Kluwer.
Colgrove, K. C., & Hargrove-Huttel, R. (2014). Prioritization, Delegation, & Management
of Care for the NCLEX-RN® Exam. FA Davis Company.
NCLEX-RN practice test questions 2018-2019: NCLEX review book with 1000 practice
exam questions for the NCLEX Registered Nursing Examination. (2018).
Houston, TX: Ascencia.
Saunders Comprehensive Review for the NCLEX-RN Examination Evolve Access
Elsevier Ebook on Vitalsource. (2016). W B Saunders