Cardiovascular Practice Questions
1) The nurse should teach the client who is receiving warfarin sodium that:
a. Partial thromboplastin time values determine the dosage of warfarin
sodium
b. Protamine sulfate is used to reverse the effects of warfarin sodium
c. International normalized ration (INR) is used to assess effectiveness
d. Warfarin sodium will facilitate clotting of the blood
2) The cardiac nurse received laboratory results on the following clients. Which
client warrants immediate intervention from the nurse?
a. The client who has an INR of 2.8.
b. The client who has a serum potassium level of 3.8 mEq/L.
c. The client who has a serum digoxin level of 2.6 mg/dL.
d. The client who has a glycosylated hemoglobin of 6%.
3) The nurse on the cardiac unit is preparing to administer medications after
receiving the morning change-of-shift report. Which medication should the nurse
administer first?
a. The cardiac glycoside to the client who has an apical pulse of 58.
b. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L.
c. The antidysrhythmic to the client in ventricular fibrillation.
d. The calcium-channel blocker who has a blood pressure of 110/68.
4) Which client should the telemetry nurse assess first after receiving the a.m. shift
report?
a. The client diagnosed with deep vein thrombosis who has an edematous
right calf.
b. The client diagnosed with varicose veins who is experiencing dull, achy
pain in their legs.
c. The client diagnosed with peripheral arterial disease who has intermittent
claudication.
d. The client diagnosed with congestive heart failure who has pink frothy
sputum.
5) The nurse is administering medications on a cardiac unit. Which medication
should the nurse question administering?
a. Warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time
(PT) of 14 and an International Normalized Ratio (INR) of 1.6 mg/dL.
b. Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of
3.3 mEq/L.
c. Atenolol (Tenormin), a beta-blocker, for the client with an aspirate
aminotransferase (AST) of 18 U/L.
d. Lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine
level of 0.8 mg/dL.
6) The nurse is administering medications to clients on a cardiac unit. Which
medication should the nurse question administering?
a. The loop-diuretic furosemide (Lasix) to a client who had a 320-mL output
in 4 hours.
b. The anticoagulant enoxaparin (Lovenox) to a client who had open-heart
surgery.
c. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery.
d. The ACE inhibitor captopril (Capoten) to a client who has a B/P of 110/68.
7) A home care nurse is visiting a client to provide follow-up evaluation and care of
a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the
ulcer is pale and deep and that the surrounding tissue is cool to the touch. The
nurse should document that these findings identify which type of ulcer?
a. A stage 1 ulcer
b. A vascular ulcer
c. An arterial ulcer
d. A venous stasis ulcer
8) A client complains of calf tenderness, and thrombophlebitis is suspected. The
nurse should next assess the client for which finding?
a. Bilateral edema
b. Increased calf circumference
c. Diminished distant peripheral pulses
d. Coolness and pallor of affected limb
9) A client is receiving cilostazol for peripheral artery disease causing intermittent
claudication. The nurse determines this medication is effective when the client
reports:
a.
b.
c.
d.
10) The nurse is assessing the lower extremities of the client with peripheral arterial
disease. Which findings are expected? Select all that apply.
a. Hairy legs
b. Mottled skin
c. Pink skin
d. Coolness
e. Moist skin
11) When assessing an individual with peripheral arterial disease, which clinical
manifestation would indicate complete arterial obstruction in the lower left leg?
a. Aching pain in the left calf
b. Burning pain in the left calf
c. Numbness and tingling in the left leg
d. Coldness of the left foot and ankle
12) The nurse is assessing a client who has a history of peripheral artery disease.
The nurse observes that the left great toe is black. The discoloration is likely a
result of:
a. Atrophy
b. Contraction
c. Gangrene
d. Rubor
13) A client with peripheral arterial disease is being discharged. The client needs
further instruction if the client states he or she will:
a. Avoid heating pads
b. Not cross the legs
c. Wear well-fited shoes
d. Use iodine on the injured site
14) One goal in caring for a client with arterial occlusive disease is to promote
vasodilation in the affected extremity. To achieve this goal, the nurse should
encourage the client to:
a. Avoid eating low fat foods
b. Elevate the legs above the heart
c. Stop smoking
d. Begin a jogging program
15) A client is being discharged after hospitalization for thrombophlebitis. They will be
riding home in a car. During the two-hour ride, what should the nurse advise the
client to do
a. Perform arm circles while riding in the car
b. Perform ankle pumps and foot range of motion exercises
c. Elevate the legs while riding in the car
d. Take an ambulance home
16) The nurse is teaching a group of women about the risk for varicose veins. Which
client is at risk for varicose veins?
a. A client who has had a cerebrovascular accident
b. A client who has had an anemia
c. A client who has had thrombophlebitis
d. A client who has had transient ischemic attacks
17) The Client is to have sclerotherapy to treat varicose veins. The nurse should
instruct the client that this procedure:
a. Causes the veins to fade and disappear
b. Ensures the varicosities will not occur again
c. Requires a short hospitalization for complete recovery
d. Results in bruising lasting for two weeks
18) 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?
a.
b.
c.
d.
be sure to elevate my leg above the level of my heart for at least
19) The nurse is planning to teach a client with peripheral arterial disease about
measures to limit disease progression. Which items should the nurse include on
a list of suggestions for the client? Select all that apply.
a. Soak the feet in hot water
b. Be careful not to injure themselves
c. Use a heating pad on the legs to aid vasodilation
d. Walk each day to increase circulation to the legs
e. Cut down on the amount of fats consumed in the diet
20) Which is the priority assessment in the care of a client who is newly admitted to
the hospital for acute arterial insufficiency of the left leg and moderate chronic
arterial insufficiency of the right leg?
a. Monitor oxygen saturation with pulse oximetry
b. Assess activity tolerance before and after exercise
c.
d. Assess peripheral pulses with an ultrasonic Doppler
21) The nurse has finished receiving the morning change-of-shift report. Which client
should the nurse assess first?
a. The client diagnosed with arterial occlusive disease who has intermittent
claudication.
b. The client on strict bed rest who is complaining of calf pain and has a
reddened calf.
c. The client who complains of low back pain when lying supine in the bed.
d.
the time.
22) The nurse on the vascular unit is caring for a client diagnosed with arterial
occlusive disease. Which statement by the client warrants immediate intervention
by the nurse?
a.
b.
c.
d.
23) Which assessment data would warrant immediate intervention by the nurse for
the client diagnosed with arterial occlusive disease?
a. The client has decreased hair on his or her calf.
b. The client has 1+ dorsalis pedal pulse.
c. The client has paralysis and paresthesia.
d. The client hangs his or her legs off the side of bed
24) A client is readmitted for a revascularization procedure for arteriosclerosis in the
left iliac artery. To promote circulation in the extremities, the nurse should
a. Position the client on a firm mattress
b. Keep the involved extremity warm with blankets
c. Position the left leg in a dangling position
d. Encourage the client to raise and lower the leg four times each hour
25) The nurse is assessing a 48-year-old client with a history of smoking during a
routine clinic visit. The client, who exercises regularly, report having pain in the
calf during exercise that disappears at rest. Which finding requires further
evaluation?
a. Heart rate 57 BPM
b. SPO2 of 94% on room air
c. Blood pressure 134/82
d. Ankle-brachial index of 0.65
26) A client with venous thrombus reports having pain in the legs. What should the
nurse do first?
a. Elevate the foot of the bed
b. Elevate the legs by using a pillow under the knees
c. Encourage adequate fluid intake
d. Massage the lower legs
27) A client is receiving an IV infusion of 5% dextrose and water. The skin around the
IV insertion site is red, warm to touch, and painful. The nurse should first:
a. Administer acetaminophen
b. Change the D5W to normal saline
c. Discontinue the IV
d. Play some dorm compress on the area
28) The clinically obese client with moderately painful varicose veins chooses selfcare options for managing the varicosities. The nurse should coach the client to
follow which healthcare practices? Select all that apply
a. Lose weight
b. Wear compression stockings
c. Apply lotion to the veins
d. Elevate the legs
e. Sleep with pillows under the knees
29) The healthcare provider has prescribed IV heparin. Before starting the
medication, the nurse should:
a. Review the blood coagulation laboratory values
b.
c. Count the client apical pulse for one minute
d. Check the 24-hour urine output record
30) The home health (HH) nurse in the office is notified the female client on warfarin
(Coumadin), an oral anticoagulant, has an International Normalized Ratio (INR)
of 3.8. Which action should the HH nurse implement first?
a. Document the result of
b. Contact the client and ask whether or not she has any abnormal bleeding
c.
d. Schedule an appointment with the client to draw another INR.
31) A client with peripheral artery disease has undergone a right femoral-popliteal
bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62
mm Hg. What should the nurse assess first?
a. IV fluid infusion rate
b. Pedal pulses
c. Nasal cannula flow rate
d. Capillary refill
32) The nurse
nurse do first?
a. Auscultate the pulses with a stethoscope.
b. Call the HCP.
c. Use a Doppler ultrasound device.
d. Inspect the left lower extremity.
33) A client with the recent diagnosis of deep vein thrombosis has sudden onset of
shortness of breath and chest pain that increases with a deep breath. The nurse
should first
a. Assess the oxygen saturation
b. Call the health care provider
c. Administer morphine sulfate 2 mg IV
d. Perform range of motion exercises in the involved leg
34) A client with a history of hypertension and peripheral vascular disease underwent
an aorta-bifemoral bypass graft. Pre-operative medications included
pentoxifylline, metoprolol, and Furosemide. On post-operative day one, the 1200
vital signs are as follows: temperature 98.9°F, heart rate 132 BPM, respiratory
rate 20 breaths/min, and blood pressure 126/78 mm Hg. Urine output is 50 to 70
mL per hour. The medications have not been prescribed for administration after
surgery. The nurse contacts the healthcare provider and recommends to:
a. Continue the pentoxifylline
b. Increase the IV fluids
c. Restart the metoprolol
d. Resume the furosemide
35) A Client has peripheral artery disease of both lower extremities. A client tells the
the client is using appropriate care management strategies?
a. The client rests with the legs elevated above the level of the heart
b. The client walks slowly but steadily for 30 minutes twice a day
c. The client limits activities to walking around the house
d. The client wears antiembolism stockings at all times when out of bed
36) Which instructions should be included in the plan of care for client who had a left
femoral popliteal bypass yesterday? Select all that apply
a. Turn frequently, and use pillows to support the incision.
b. Encourage client to change positions frequently to prevent atelectasis
c. Place the left leg in the knee flexed position to promote oxygenation
d. Place the client in supine position, and elevate the leg above the heart to
prevent edema.
e. Encourage the client to walk short distances to promote circulation
f. Encourage the client to maintain bedrest to prevent stress on the suture
line
37) A client is being treated for deep vein thrombosis in the left femoral artery. The
healthcare provider has prescribed 60 mg of enoxaparin subcutaneously. Before
following values:
Pro thrombin time 12.5 seconds
INR 2.0 seconds
Platelet count 50,000 u/L
Based on these results what should the nurse do?
a) Contact the pharmacist for a lower dose of the medication
b) Administer the medication as prescribed
c) Assess the client for signs of bruising on the extremities
d) Withhold the dose of the medication and contact the HCP
38) The nurses caring for client with the venous thrombosis of the left lower
extremity. To prevent further tissue damage, it is important for the nurse to
observe for which finding?
a. Blood pressure and heart rate changes
b. Gradual or acute loss of sensory and motor functions
c. Metabolic acidosis
d. Swelling in the left lower extremity
39) The nurse is performing an assessment on a client with a diagnosis of left-sided
heart failure. Which assessment component would elicit specific information
regarding the client's left-sided heart function?
a. Listening to lung sounds
b. Palpating for organomegaly
c. Assessing for jugular vein distention
d. Assessing for peripheral and sacral edema
40) Spironolactone 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?
a. Calcium
b. Potassium
c. Magnesium
d. Phosphorous
41) A client has been admitted with left-sided heart failure. When planning care for
the client, interventions should be focused on reduction of which specific problem
associated with this type of heart failure?
a. Ascites
b. Pedal edema
c. Bilateral lung crackles
d. Jugular vein distention
42) A client with chronic heart failure has atrial fibrillation and a left ventricular
ejection fraction of 15%. The client is taking warfarin. The expected outcome of
this drug is to:
a. Decrease circulatory overload
b. Improve myocardial workload
c. Prevent thrombus formation
d. Regulate cardiac rhythm
43) Which position is best for a client with heart failure who has orthopnea?
a.
b.
c.
resting on the mattress
d.
elevated
44) A client with heart failure is receiving digoxin intravenously. The nurse should
determine the effectiveness of the drug by assessing:
a. Dilated coronary arteries
b. Increased myocardial contractility
c. Decreased cardiac arrhythmias
d. Decreased electrical conductivity in the heart
45) The nurse teaches a client with heart failure to take oral furosemide in the
morning. The primary reason for this is to prevent:
a. Electrolyte imbalances
b. Nausea or vomiting
c. Excretion of excessive fluids accumulated during the night
d. Sleep disturbances during the night
46) The nurse should teach the client that signs of digoxin toxicity include:
a. Rash over the chest and back
b. Increased appetite
c. Visual disturbances such as seeing yellow spots
d. Elevated blood pressure
47) The nurse should assess the client for digoxin toxicity if serum levels indicate that
the client has a:
a. Low sodium level
b. High glucose level
c. High calcium level
d. Low potassium level
48) Which food should the nurse teach a client with heart failure to limit when
following a 2-g sodium diet?
a. Apples
b. Canned tomato juice
c. Whole wheat bread
d. Beef tenderloin
49) A client receiving a loop diuretic should be encouraged to eat which foods?
Select all that apply
a. Angel food cake
b. Banana
c. Dried fruit
d. Orange juice
e. Peppers
50) A client has a history of heart failure and has been prescribed furosemide,
digoxin, and potassium chloride. The client has nausea, blurred vision,
headache, and weakness. The nurse notes that the client is confused. The
telemetry strip shows first-degree atrioventricular block. The nurse should
assess the client for signs of:
a. Hyperkalemia
b. Digoxin toxicity
c. Fluid deficit
d. Pulmonary edema
51) Which are indications that a client with a history of left-sided heart failure is
developing pulmonary edema? Select all that apply
a. Distended jugular veins
b. Dependent edema
c. Anorexia
d. Coarse crackles
e. Tachycardia
52) What is the major goal of nursing care for a client with heart failure and
pulmonary edema?
a. Increase cardiac output
b. Improve exercise tolerance
c. Decrease peripheral edema
d. Enhance comfort
53) Which of the following discharge teaching is most appropriate for a client being
discharged with heart failure?
a. Maintain a high-fiber diet
b. Walking 2 miles every day
c. Obtaining daily weights at the same time each day
d. Remaining sedentary for most of the day
54) The nurse is teaching a client with heart failure how to avoid complications and
future hospitalizations. The nurse is confident that the client has understood the
teaching when the client identifies which potential complications that need to be
reported to their physician? Select all that apply.
a. Becoming increasingly short of breath at rest
b. Weight gain of 2 lbs or more in 1 day
c. High intake of sodium for breakfast
d. Having to sleep sitting up in a reclining chair
e. Weight loss of 2 lbs in 1 day
55) The cardiac nurse is teaching the client diagnosed with congestive heart failure.
Which teaching interventions should the nurse discuss with the client? Select all
that apply.
a. Notify the healthcare provider (HCP) if the client gains more than 2 lb in
one day.
b. Keep the head of the bed elevated when sleeping.
c. Take the loop diuretic once a day before going to sleep.
d. Teach the client which foods are high in sodium and should be avoided.
e. Perform isotonic exercises at least once a day.
56) The nurse is auscultating a 56-year-old adult client's apical heart rate before
giving digoxin and notes that the heart rate is 48 beats/minute. Which action
should the nurse take?
a. Withhold the digoxin and re-evaluate the heart rate in 4 hours.
b. Administer half of the prescribed dose to avoid a further decrease in heart
rate
c. Withhold the digoxin, and assess for sign of decreased cardiac output and
digoxin toxicity
d. Administer the digoxin; the heart rate would be considered normal
57) Captopril, furosemide, and metoprolol are prescribed for a client with systolic
lood pressure is 136/82 mm Hg, and the clients heart
rate is 65 bpm. Prior to medication administration at 0900 the nurse reviews the
patients labs and notes the following findings. What should the nurse do first?
Sodium 140 mEq/L
Potassium 6.8 mEq/L
BUN 18 mg/dL
Creatinine 1.0 mg/dL
Hemoglobin 12 g/dL
Hematocrit 37%
a.
b.
c.
d.
Administer the medications
Call the healthcare provider
Withhold the captopril
Question the metoprolol dose
58) The nurse is admitting an older adult to the hospital. The echocardiogram report
revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the
ankles when getting client out of bed. Based on this finding, what should the
nurse do first?
a.
Assess respiratory status
b.
Draw blood for laboratory studies
c.
Insert a foley catheter
d.
Weight the client
59) The nurse is assessing a client with heart failure whose blood pressure and
weight are being monitored remotely. The nurse reviews data obtained within
the last 3 days:
April 3
April 4
April 5
Weight
160 lbs 162 lbs 165 lbs
Blood
120/80 130/88 140/90
Pressure
The nurse calls the client to follow up. The nurse should first ask the client:
a.
b.
c.
d.
60) The nurse is providing instructions to a client with a diagnosis of hypertension
regarding high-sodium items to be avoided. The nurse instructs the client to
avoid consuming which item?
a. Bananas
b. Broccoli
c. Antacids
d. Cantaloupe
61) The nurse in the medical unit is reviewing the laboratory test results for a client
who has been transferred from the intensive care unit (ICU). The nurse notes
that a cardiac troponin T assay was performed while the client was in the ICU.
The nurse determines that this test was performed to assist in diagnosing which
condition?
a. Heart failure
b. Atrial fibrillation
c. Myocardial infarction
d. Ventricular tachycardia
62) The nurse has provided dietary instructions to a client with coronary artery
disease. Which statement by the client indicates an understanding of the dietary
instructions?
a.
b.
c.
d.
63) A client with coronary artery disease is scheduled to have a diagnostic exercise
stress test. Which instruction should the nurse plan to provide to the client about
this procedure?
a. Eat breakfast just before the procedure
b. Wear firm, rigid shoes, such as working boots
c. Wear loose clothing with a shirt that buttons in front
d. Avoid cigarettes for 30 minutes before the procedure
64) A client with a history of hypertension has been prescribed triamterene. The
nurse determines that the client understands the effect of this medication on the
diet if the client states to avoid which fruit?
a. Pears
b. Apples
c. Bananas
d. Cranberries
65) The client has been managing angina episodes with nitroglycerin. Which finding
indicates that the therapeutic effect of the drug has been achieved?
a. Decreased chest pain
b. Increased blood pressure
c. Decreased blood pressure
d. Decreased heart rate
66) The client who experiences angina has been told to follow a low-cholesterol diet.
Which meal would be best?
a. Hamburger, salad, and milk shake
b. Baked liver, green beans, and coffee
c. Spaghetti with tomato sauce, salad, and coffee
d. Fried chicken, green beans, and skim milk
67) A client with unstable angina is schedule to have a cardiac catheterization. The
nurse explains to the client that this procedure is being used for:
a. Decrease hypertension
b. Assess the extent of coronary artery blockage
c. Bypass obstructed vessels
d. Assess the functional adequacy of the valves and heart muscle
68) Metoprolol is added to the pharmacological therapy of a diabetic female
diagnosed with stage 2 hypertension who has been initially treated with
furosemide and rampiril. An expected therapeutic effect is:
a. Decrease the heart rate
b. Lessening of fatigue
c. Improvement in blood sugar levels
d. Increase in urine output
69) A client is taking clonidine for the treatment of hypertension. The nurse should
teach the client about which common side effects of this drug? Select all that
apply.
a. Dry mouth
b. Hyperkalemia
c. Impotence
d. Pancreatitis
e. Sleep disturbance
70) When teaching a client about propranolol hydrochloride, the nurse should base
the information on the knowledge that propranolol:
a. Blocks beta-adrenergic stimulation and thus causes decreased heart rate,
myocardial contractility, and conduction
b. Increases norepinephrine secretion and thus decreases blood pressure
and heart rate
c. Is a potent arterial and venous vasodilator that reduces peripheral
vascular resistance and lowers blood pressure
d. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure
by blocking the conversion of angiotensin I to angiotensin II
71) A client with no history of cardiovascular disease comes to the ambulatory clinic
with flulike symptoms. The client suddenly complains of chest pain. Which
question should best help the nurse discriminate pain caused by a noncardiac
problem?
a.
b.
c.
d.
72) An ambulatory care nurse measures the blood pressure of a client and finds it to
be 156/94 mm Hg. Which statement indicates that the client needs additional
education?
a.
b.
c.
d.
73) A client returns from a left heart catheterization. The right groin was used for
catheter access. In which location should the nurse palpate the distal pulse on
this client?
a. Anterior to the right tibia
b. Dorsal surface of the right foot
c. Posterior to the right knee
d. Right midinguinal area
74) An older adult has chest pain and shortness of breath. The healthcare provider
prescribes nitroglycerin tablets. What should the nurse instruct the client to do?
a. Put the tablet under the tongue until it is absorbed
b. Swallow the tablet with 120 mL of water
c. Chew the tablet until it is dissolved
d. Place the tablet between the cheek and gums until it disappears
75) The nurse is caring for a client who recently experienced a myocardial infarction
and has been started on clopidogrel. The nurse should develop a teaching plan
that includes which points? Select all that apply.
a. The client should report unexpected bleeding or bleeding that lasts a long
time.
b. The client should take clopidogrel with food.
c. The client may bruise more easily and may experience bleeding gums.
d. Clopidogrel works by preventing platelets from sticking together and
forming a clot.
e. The client should drink a glass of water after taking clopidogrel.
76) Following diagnosis of angina pectoris, a client reports being unable to walk up
two flights of stairs without pain. Which instructions would most likely help the
client prevent this problem?
a. Climb the steps early in the day.
b. Rest for at least an hour before climbing the stairs.
c. Take a nitroglycerin tablet before climbing the stairs
d. Lie down after climbing the stairs
77) A client with angina is taking nifedipine. What instructions should the nurse give
the client?
a. Monitor blood pressure monthly
b. Perform daily weights
c. Inspect gums daily
d. Limit intake of green, leafy vegetables
78) The nurse is developing a teaching plan for a client who will be starting a
prescription for simvastatin 40 mg/day. What instructions should the nurse give
the client? Select all that apply.
a.
b.
c.
d.
e.
f.
79) Which set of postural vital signs indicate inadequate blood volume?
a. Supine 124/76, 88 Sitting 124/74, 92 Standing 122/74, 92
b. Supine 120/70, 70 Sitting 102/64, 86 Standing 100/60, 92
c. Supine 138/86, 74 Sitting 136/84, 80 Standing 134/82, 82
d. Supine 100/70, 72 Sitting 100/68, 74 Standing 98/68, 80
80) The nurse is discussing medications with a client with hypertension who has a
prescription for furosemide daily. The client needs further education when the
client states:
a.
b.
c.
d.
81) In teaching the client with hypertension to avoid orthostatic hypotension, the
nurse should teach the client to follow which instructions? Select all that apply.
a. Plan regular times for taking medications
b. Arise slowly from bed
c. Avoid standing still for long periods
d. Avoid excessive alcohol intake
e. Avoid hot baths
82) The nurse is teaching a client with hypertension about taking atenolol. The nurse
should instruct the client to
a. Avoid sudden discontinuation of the drug
b. Monitor the blood pressure annually
c. Follow a low protein diet
d. Discontinue the medication if severe headaches develop
83) The nurse teaches a client who has recently been diagnosed with hypertension
about following a low-calorie, low-fat, low-sodium diet. Which of the following
menu selections would best meet the client
a. Mixed green salad with blue cheese dressing, crackers, and cold cuts
b. Ham sandwich on rye bread and an orange
c. Baked chicken, an apple, and a slice of bread
d. Hot dogs, baked beans, and celery and carrot sticks
84) A client who has diabetes is taking metoprolol for hypertension. What should the
nurse instruct the client to do? Select all that apply.
a. Take the tablets with food at the same each day
b. Do not crush or chew the tablets
c. Notify the healthcare provider if pulse is 82 beats/min
d. Use an appropriate decongestant if needed
e. Report any fainting spells to the HCP
85) A client is diagnosed with primary (essential) hypertension is taking
chlorothiazide. The nurse determines teaching is effective when the client makes
all that apply)
a.
b.
c.
d.
e.
f. Tak
86) A 68-year-old client on day 2 after hip surgery has no cardiac history but reports
having chest heaviness. The nurse should first:
a. Inquire about the onset, duration, severity, and precipitating factors of the
heaviness.
b. Administer oxygen via nasal cannula
c. Offer pain medications for the chest heaviness
d. Inform the healthcare provider of the chest heaviness
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
the normal range
3.5 to 5.5 mEq/L. Therefore, this client would not need
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
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,
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
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
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
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
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
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
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
ect. 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.
ntion. (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)
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,
ervention.
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
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
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
d be used if the client could not tolerate high
good position for the client in heart failure. The client in heart failure would
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
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
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
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
ate 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
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.
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
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