2023 ATI RN Leadership Proctored Exam With Answers-135 Solved Questions

ATI RN LEADERSHIP PROCTORED EXAM 2023 VERSION 123 LATEST UPDATE
COMPLETE QNS &ANS
1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain,
and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse
takes priority?
A. Assess the client's lung sounds.
B. Notify the Rapid Response Team.
C. Provide reassurance to the client.
D. Take a full set of vital signs.
Answer: B. Notify the Rapid Response Team.
Explanation:
This client has manifestations of a pulmonary embolism, and the most critical action is to notify
the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate
also but are not the priority.
2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active
and has no known risk factors for PE. What action by the nurse is most appropriate?
A. Encourage the client to walk 5 minutes each hour.
B. Refer the client to smoking cessation classes.
C. Teach the client about factor V Leiden testing.
D. Tell the client that sometimes no cause for disease is found.
Answer: C. Teach the client about factor V Leiden testing.
Explanation:
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,
including PE. A client with no known risk factors for this disorder should be referred for testing.
Encouraging the client to walk is healthy, but is not related to the development of a PE in this
case, nor is smoking. Although there are cases of disease where no cause is ever found, this
assumption is premature.

3. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the
client's oxygen saturation has not significantly improved. What response by the nurse is best?
A. "Breathing so rapidly interferes with oxygenation."
B. "Maybe the client has respiratory distress syndrome."
C. "The blood clot interferes with perfusion in the lungs."
D "The client needs immediate intubation and mechanical ventilation."
Answer: C. "The blood clot interferes with perfusion in the lungs."
Explanation:
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless
the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and
this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but
this is not as likely. The client may need to be mechanically ventilated, but without concrete data
on FiO2 and SaO2, the nurse cannot make that judgment.
4. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent
partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
A. Decrease the heparin rate.
B. Increase the heparin rate.
C. No change to the heparin rate.
D. Stop heparin; start warfarin
Answer: B. Increase the heparin rate.
Explanation:
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the
heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The
heparin rate needs to be increased. Warfarin is not indicated in this situation.
5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic
testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is
best?
A. Instruct the client to eliminate all vitamin K from the diet.

B. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
C. Refer the client to a chronic illness support group.
D. Teach the client to use a soft-bristled toothbrush.
Answer: B. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
Explanation:
Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However,
clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher
blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the
prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare
to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K
from the diet. A chronic illness support group may be needed, but this is not the best intervention
as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure
for clients on anticoagulation therapy.
6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value
possibly indicates that a serious side effect has occurred?
A. Haemoglobin: 14.2 g/dL
B. Platelet count: 82,000/L
C. Red blood cell count: 4.8/mm3
D. White blood cell count: 8.7/mm3
Answer: B. Platelet count: 82,000/L
Explanation:
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other
values are normal for either gender.
7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
A. Assess for other manifestations of hypoxia.
B. Change the sensor on the pulse oximeter.
C. Obtain a new oximeter from central supply.
D. Tell the client to take slow, deep breaths
Answer: A. Assess for other manifestations of hypoxia.

Explanation:
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can
interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should
conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.
8. A nurse is assisting the health care provider who is intubating a client. The provider has been
attempting to intubate for 40 seconds. What action by the nurse takes priority?
A. Ensure the client has adequate sedation.
B. Find another provider to intubate.
C. Interrupt the procedure to give oxygen.
D. Monitor the client's oxygen saturation.
Answer: C. Interrupt the procedure to give oxygen.
Explanation:
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia.
The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should
also have adequate sedation during the procedure and monitor the client's oxygen saturation, but
these do not take priority. Finding another provider is not appropriate at this time.
9. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes
priority?
A. Determine if the tube is kinked.
B. Ensure all connections are patent.
C. Listen to the client's lung sounds.
D. Suction the endotracheal tube.
Answer: C. Listen to the client's lung sounds.
Explanation:
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most
common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The
nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still
correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess
the patency of the tube and connections and perform suction.

10. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed
assistive personnel (UAP)?
A. Assess the client for sedation needs.
B. Get family permission for restraints.
C. Provide frequent oral care per protocol.
D. Use nonverbal pain assessment tools.
Answer: C. Provide frequent oral care per protocol.
Explanation:
The client on mechanical ventilation needs frequent oral care, which can be delegated to the
UAP. The other actions fall within the scope of practice of the nurse.
11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator
settings with the respiratory therapist, what should the nurse ensure as a priority?
A. The client is able to initiate spontaneous breaths.
B. The inspired oxygen has adequate humidification.
C. The upper peak airway pressure limit alarm is off.
D. The upper peak airway pressure limit alarm is on.
Answer: D. The upper peak airway pressure limit alarm is on.
Explanation:
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset
maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off.
Initiating spontaneous breathing is important for some modes of ventilation but not others.
Adequate humidification is important but does not take priority over preventing injury.
12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and
thrashing about. What action by the nurse is most appropriate?
A. Assess the cause of the agitation.
B. Reassure the client that he or she is safe.
C. Restrain the client's hands.
D. Sedate the client immediately.
Answer: A. Assess the cause of the agitation.

Explanation:
The nurse needs to determine the cause of the agitation.
13. A nurse is preparing to admit a client on mechanical ventilation from the emergency
department. What action by the nurse takes priority?
A. Assessing that the ventilator settings are correct
B. Ensuring there is a bag-valve-mask in the room
C. Obtaining personal protective equipment
D. Planning to suction the client upon arrival to the room
Answer: B. Ensuring there is a bag-valve-mask in the room
Explanation:
Having a bag-valve-mask device is critical in case the client needs manual breathing. The
respiratory therapist is usually primarily responsible for setting up the ventilator, although the
nurse should know and check the settings. Personal protective equipment is important, but
ensuring client safety takes priority. The client may or may not need suctioning on arrival.
14. A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac)
is needed since the client "only has lung problems." What response by the nurse is best?
A "It will increase the motility of the gastrointestinal tract."
B. "It will keep the gastrointestinal tract functioning normally."
C. "It will prepare the gastrointestinal tract for enteral feedings."
D. "It will prevent ulcers from the stress of mechanical ventilation."
Answer: D. "It will prevent ulcers from the stress of mechanical ventilation."
Explanation:
Stress ulcers occur in many clients who are receiving mechanical ventilation, and often
prophylactic medications are used to prevent them. Frequently used medications include
antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.
15. A client has been brought to the emergency department with a life-threatening chest injury.
What action by the nurse takes priority?
A. Apply oxygen at 100%.

B. Assess the respiratory rate.
C. Ensure a patent airway.
D. Start two large-bore IV lines.
Answer: C. Ensure a patent airway.
Explanation:
The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures
the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed
by inserting IVs.
16. A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner
indicates the client needs more education regarding this medication?
A. Hamburger and French fries
B. Large chef's salad and muffin
C. No selection; spouse brings pizza
D. Tuna salad sandwich and chips
Answer: B. Large chef's salad and muffin
Explanation:
Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high
in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts.
The chef's salad most likely has too many leafy green vegetables, which contain high amounts of
vitamin K. The other selections, while not particularly healthy, will not interfere with the
medication's mechanism of action.
17. A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the
nurse indicates a possible barrier to self- management?
A. Poor visual acuity
B. Strict vegetarian
C. Refusal to stop smoking
D. Wants weight loss surgery
Answer: B. Strict vegetarian
Explanation:

Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high
in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts.
A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility
with the client. The other options are not related.
18. A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by
the student requires immediate intervention by the supervising nurse?
A. Assessing the client's platelet count
B. Choosing an 18-gauge, 2-inch needle
C. Not aspirating prior to injection
D. Swabbing the injection site with alcohol
Answer: B. Choosing an 18-gauge, 2-inch needle
Explanation:
Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions
are appropriate
19. A client in the emergency department has several broken ribs. What care measure will best
promote comfort?
A. Allowing the client to choose the position in bed
B. Humidifying the supplemental oxygen
C. Offering frequent, small drinks of water
D. Providing warmed blankets
Answer: A. Allowing the client to choose the position in bed
Explanation:
Allow the client with respiratory problems to assume a position of comfort if it does not interfere
with care. Often the client will choose a more upright position, which also improves
oxygenation. The other options are less effective comfort measures.
20. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping
blood pressure. What medication should the nurse anticipate, the client will need as the priority?
A. Alteplase (Activase)

B. Enoxaparin (Lovenox)
C. Unfractionated heparin
D. Warfarin sodium (Coumadin)
Answer: A. Alteplase (Activase)
Explanation:
Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic
instability. The nurse knows this drug is the priority, although heparin may be started initially.
Enoxaparin and warfarin are not indicated in this setting.
21. A client is brought to the emergency department after sustaining injuries in a severe car crash.
The client's chest wall does not appear to be moving normally with respirations, oxygen
saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?
A. Administer oxygen and reassess.
B. Auscultate the client's lung sounds.
C. Facilitate a portable chest x-ray.
D. Prepare to assist with intubation.
Answer: D. Prepare to assist with intubation.
Explanation:
This client has manifestations of flail chest and, with the other signs, needs to be intubated and
mechanically ventilated immediately. The nurse does not have time to administer oxygen and
wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is
intubated.
22. A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse
instructor is best?
A. "It is chronic hypoxemia that accompanies restrictive airway disease."
B. "It is hypoxemia from lung damage due to mechanical ventilation."
C. "It is hypoxemia that continues even after the client is weaned from oxygen."
D. "It is hypoxemia that persists even with 100% oxygen administration."
Answer: D. "It is hypoxemia that persists even with 100% oxygen administration."
Explanation:

Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen.
It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive
airway disease and is not caused by the use of mechanical ventilation or by being weaned from
oxygen.
23. A nurse is caring for a client on the medical stepdown unit. The following data are related to
this client: Subjective Information Laboratory Analysis Physical Assessment
Shortness of breath for 20 minutes Feels frightened
"Can't catch my breath" pH:
7.12 PaCO2: 28 mm Hg
PaO2: 58 mm Hg
SaO2: 88%
Pulse: 120 beats/min
Respiratory rate: 34 breaths/min
Blood pressure:158/92 mm Hg
Lungs have crackles
What action by the nurse is most appropriate?
A. Call respiratory therapy for a breathing treatment.
B. Facilitate a STAT pulmonary angiography.
C. Prepare for immediate endotracheal intubation.
D. Prepare to administer intravenous anticoagulants.
Answer: B. Facilitate a STAT pulmonary angiography.
Explanation:
This client has manifestations of pulmonary embolism (PE); however, many conditions can
cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography.
The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a
respiratory treatment is not needed. The client is not unstable enough to need intubation and
mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.

24. The nurse assesses a client with asthma and finds wheezing throughout the lung fields and
decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on
inhalation. What is the nurse's best action?
A. Perform peak expiratory flow readings.
B. Assess for a midline trachea.
C. Administer oxygen and a rescue inhaler.
D. Call a code.
Answer: C. Administer oxygen and a rescue inhaler.
Explanation:
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory
muscles and is having difficulty moving air into the respiratory passages because of airway
narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also
supports this finding. The asthma is not responding to the medication, and intervention is needed.
Administration of a rescue inhaler is indicated, probably along with administration of oxygen.
The nurse would not do a peak flow reading at this time, nor would a code be called. Midline
trachea is a normal and expected finding.
25. A client has a mediastinal chest tube. Which symptoms require the nurse's immediate
intervention? (Select all that apply.)
A. Production of pink sputum
B Tracheal deviation
C. Oxygen saturation greater than 95%
D. Sudden onset of shortness of breath
E. Drainage greater than 70 mL/hr
F. Pain at insertion site
G. Disconnection at Y site
Answer: B Tracheal deviation
D. Sudden onset of shortness of breath
E. Drainage greater than 70 mL/hr
G. Disconnection at Y site
Explanation:

Immediate intervention is warranted if the client has tracheal deviation because this could
indicate a tension pneumothorax; sudden shortness of breath because this could indicate
dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70
mL/hr because this could indicate haemorrhage. Disconnection at the Y site could result in air
entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the
insertion site are not signs/symptoms that would require immediate intervention.
26. A nurse assesses a client who has a chest tube. For which manifestations should the nurse
immediately intervene? (Select all that apply.)
A. Production of pink sputum
B. Tracheal deviation
C. Sudden onset of shortness of breath
D. Pain at insertion site
E. Drainage of 75 mL/hr
Answer: B. Tracheal deviation
C. Sudden onset of shortness of breath
Explanation:
Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension
pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum
is associated with pulmonary edema and is not a complication of a chest tube. Pain at the
insertion site and drainage of 75 mL/hr are normal findings with a chest tube.
27. A nurse is caring for five clients. For which clients would the nurse assess a high risk for
developing a pulmonary embolism (PE)? (Select all that apply.)
A. Client who had a reaction to contrast dye yesterday
B. Client with a new spinal cord injury on a rotating bed
C. Middle-aged man with an exacerbation of asthma
D. Older client who is 1-day post hip replacement surgery
E. Young obese client with a fractured femur
Answer: B. Client with a new spinal cord injury on a rotating bed
D. Older client who is 1-day post hip replacement surgery

E. Young obese client with a fractured femur
Explanation:
Conditions that place clients at higher risk of developing PE include prolonged immobility,
central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting,
history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer
(particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for
PE.
28. When working with women who are taking hormonal birth control, what health promotion
measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that
apply.)
A. Avoid drinking alcohol.
B. Eat more omega-3 fatty acids.
C. Exercise on a regular basis.
D. Maintain a healthy weight.
E. Stop smoking cigarettes.
Answer: C. Exercise on a regular basis.
D. Maintain a healthy weight.
E. Stop smoking cigarettes.
Explanation:
Health promotion measures for clients to prevent thromboembolic events such as PE include
maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol
and eating more foods containing omega-3 fatty acids are heart- healthy actions but do not relate
to the prevention of PE.
29. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most
appropriate? (Select all that apply.)
A. Acknowledge the frightening nature of the illness.
B. Delegate a back rub to the unlicensed assistive personnel (UAP).
C. Give simple explanations of what is happening.
D. Request a prescription for antianxiety medication.

E. Stay with the client and speak in a quiet, calm voice.
Answer: A. Acknowledge the frightening nature of the illness.
B. Delegate a back rub to the unlicensed assistive personnel (UAP).
C. Give simple explanations of what is happening.
E. Stay with the client and speak in a quiet, calm voice.
Explanation:
Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate
comfort measures, give simple explanations the client will understand, and stay with the client.
Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used
routinely because they can contribute to hypoxia. If the client's anxiety is interfering with
diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.
30. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilatorassociated pneumonia. What actions are included in this practice? (Select all that apply.)
A. Adherence to proper hand hygiene
B. Administering anti-ulcer medication
C. Elevating the head of the bed
D. Providing oral care per protocol
E. Suctioning the client on a regular schedule
Answer: A. Adherence to proper hand hygiene
B. Administering anti-ulcer medication
C. Elevating the head of the bed
D. Providing oral care per protocol
Explanation:
The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia.
Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications,
elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and
providing pulmonary hygiene measures. Suctioning is done as needed.
31. A nurse is caring for a client who is on mechanical ventilation. What actions will promote
comfort in this client? (Select all that apply.)

A. Allow visitors at the client's bedside.
B. Ensure the client can communicate if awake.
C. Keep the television tuned to a favorite channel.
D. Provide back and hand massages when turning.
E. Turn the client every 2 hours or more.
Answer:
A. Allow visitors at the client's bedside.
B. Ensure the client can communicate if awake.
D. Provide back and hand massages when turning.
E. Turn the client every 2 hours or more.
Explanation:
There are many basic care measures that can be employed for the client who is on a ventilator.
Allowing visitation, providing a means of communication, massaging the client's skin, and
routinely turning and repositioning the client are some of them. Keeping the TV on will interfere
with sleep and rest.
32. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk
for weaning failure. What age related changes contribute to this? (Select all that apply.)
A. Chest wall stiffness
B. Decreased muscle strength
C. Inability to cooperate
D. Less lung elasticity
E. Poor vision and hearing
Answer: A. Chest wall stiffness
B. Decreased muscle strength
D. Less lung elasticity
Explanation:
Age-related changes that increase the difficulty of weaning older adults from mechanical
ventilation include increased stiffness of chest wall, decreased muscle strength, and less elasticity
of lung tissue.

33. A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting
should the nurse anticipate for tidal volume? (Record your answer using a whole number.)
Answer: 660 mL
Explanation:
A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg.
110 kg × 6 mL/kg = 660 mL.
34. A nursing student caring for a client removes the client's oxygen as prescribed. The client is
now breathing what percentage of oxygen in the room air?
A. 14%
B. 21%
C. 28%
D. 31%
Answer: B. 21%
Explanation:
Room air is 21% oxygen.
35. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is
the priority?
A. Administer prescribed anxiolytic medication.
B. Ensure informed consent is on the chart.
C. Reinforce any teaching done previously.
D. Start the preoperative antibiotic infusion.
Answer: B. Ensure informed consent is on the chart.
Explanation:
Since this is an operative procedure, the client must sign an informed consent, which must be on
the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do
not take priority.
36. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's
face is puffy and the eyelids are swollen. What action by the nurse takes priority?

A. Assess the client's oxygen saturation.
B. Notify the Rapid Response Team.
C. Oxygenate the client with a bag-valve-mask.
D. Palpate the skin of the upper chest.
Answer: A. Assess the client's oxygen saturation.
Explanation:
This client may have subcutaneous emphysema, which is air that leaks into the tissues
surrounding the tracheostomy. The nurse should first assess the client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper
chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using
a bag-valve-mask device may or may not be appropriate for the unstable client.
37. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles
are noted. What action by the nurse is best?
A. Elevate the head of the client's bed.
B. Measure and compare cuff pressures.
C. Place the client on NPO status.
D. Request that the client have a swallow study.
Answer: B. Measure and compare cuff pressures.
Explanation:
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation
of the tracheal passage. This can be manifested by food particles seen in secretions or by noting
that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The
nurse should measure the pressures and compare them to previous ones to detect a trend.
Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study
will not correct this situation.
38. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that
evening, the UAP reports that the client had a coughing spell during the meal. What action by the
nurse takes priority?
A. Assess the client's lung sounds.

B. Assign a different UAP to the client.
C. Report the UAP to the manager.
D. Request thicker liquids for meals.
Answer: A. Assess the client's lung sounds.
Explanation:
The priority is to check the client's oxygenation because he or she may have aspirated. Once the
client has been assessed, the nurse can consult with the registered dietitian about appropriately
thickened liquids. The UAP should have reported the incident immediately, but addressing that
issue is not the immediate priority.
39. A student nurse is providing tracheostomy care. What action by the student requires
intervention by the instructor?
A. Holding the device securely when changing ties
B. Suctioning the client first if secretions are present
C. Tying a square knot at the back of the neck
D. Using half-strength peroxide for cleansing
Answer: C. Tying a square knot at the back of the neck
Explanation:
To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot
should be placed at the side of the client's neck, not in back. The other actions are appropriate.
40. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the
student demonstrates that more teaching is needed?
A. Applying suction while inserting the catheter
B. Preoxygenating the client prior to suctioning
C. Suctioning for a total of three times if needed
D. Suctioning for only 10 to 15 seconds each time
Answer: A. Applying suction while inserting the catheter
Explanation:
Suction should only be applied while withdrawing the catheter. The other actions are appropriate.

41. A nurse is caring for a client using oxygen while in the hospital. What assessment finding
indicates that goals for a priority diagnosis are being met?
A. 100% of meals being eaten by the client
B. Intact skin behind the ears
C. The client understanding the need for oxygen
D. Unchanged weight for the past 3 days
Answer: B. Intact skin behind the ears
Explanation:
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of
Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis
are being met. Nutrition and weight are not related to using oxygen. Understanding the need for
oxygen is important but would not take priority over a physical problem.
42. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy
tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings
are noted. What action by the nurse is most appropriate?
A. Call the operating room to inform them of a pending emergency case.
B. No action is needed at this time; this is a normal finding in some clients.
C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
D. Stay with the client and have someone else call the provider immediately.
Answer: D. Stay with the client and have someone else call the provider immediately.
Explanation:
This client may have a trachea-innominate artery fistula, which can be a life-threatening
emergency if the artery is breached and the client begins to haemorrhage. Since no bleeding is
yet present, the nurse stays with the client and asks someone else to notify the provider. If the
client begins haemorrhaging, the nurse removes the tracheostomy and applies pressure at the
bleeding site. The client will need to be prepared for surgery.
43. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the
nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
A. The client demonstrates good understanding of stoma care.

B. The client has joined a book club that meets at the library.
C. Family members take turns assisting with stoma care.
D. Skin around the stoma is intact without signs of infection.
Answer: B. The client has joined a book club that meets at the library.
Explanation:
The client joining a book club that meets outside the home and requires him or her to go out in
public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are
all positive signs but do not relate to this nursing diagnosis.
44. A client is receiving oxygen at 4 Liters per nasal cannula. What comfort measure may the
nurse delegate to unlicensed assistive personnel (UAP)?
A. Apply water-soluble ointment to nares and lips.
B. Periodically turn the oxygen down or off.
C. Remove the tubing from the client's nose.
D. Turn the client every 2 hours or as needed.
Answer: A. Apply water-soluble ointment to nares and lips.
Explanation:
Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and
nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client
is not related to comfort measures for oxygen.
45. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What
action by the nurse is best?
A. Assess the client's oxygen saturation and, if normal, turn off the oxygen.
B. Determine if the client can switch to a nasal cannula during the meal.
C. Have the client lift the mask off the face when taking bites of food.
D. Turn the oxygen off while the client eats the meal and then restart it.
Answer: B. Determine if the client can switch to a nasal cannula during the meal.
Explanation:
Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the
provider has approved switching to a nasal cannula during meals. If not, the nurse should consult

with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat
will alter the FiO2 delivered. The nurse assesses the client using the device pictured below to
deliver 50% O2:
46. The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the
flow rate of the oxygen is 3 L/min. What action by the nurse is best?
A. Assess the client's oxygen saturation.
B. Document these findings in the chart.
C. Immediately increase the flow rate.
D. Turn the flow rate down to 2 L/min.
Answer: C. Immediately increase the flow rate.
Explanation:
For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually
between 4 and 10 L/min. The client's flow rate is too low and the nurse should increase it. After
increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings
47. A home health nurse is visiting a new client who uses oxygen in the home. For which factors
does the nurse assess when determining if the client is using the oxygen safely? (Select all that
apply.)
A. The client does not allow smoking in the house.
B. Electrical cords are in good working order.
C. Flammable liquids are stored in the garage.
D. Household light bulbs are the fluorescent type.
E. The client does not have pets inside the home.
Answer: A. The client does not allow smoking in the house.
B. Electrical cords are in good working order.
C. Flammable liquids are stored in the garage.
Explanation:
Oxygen is an accelerant, which means it enhances combustion, so precautions are needed
whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether

electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in
the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.
48. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse
delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)
A. Applying water-soluble lip balm to the client's lips
B. Ensuring the humidification provided is adequate
C. Performing oral care with alcohol-based mouthwash
D. Reminding the client to cough and deep breathe often
E. Suctioning excess secretions through the tracheostomy
Answer: A. Applying water-soluble lip balm to the client's lips
D. Reminding the client to cough and deep breathe often
Explanation:
The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such
as reminding the client to perform coughing and deep-breathing exercises. Oral care can be
accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is
adequate and suctioning through the tracheostomy are nursing functions.
49. A client is being discharged home after having a tracheostomy placed. What suggestions does
the nurse offer to help the client maintain self-esteem? (Select all that apply.)
A. Create a communication system.
B. Don't go out in public alone.
C. Find hobbies to enjoy at home.
D. Try loose-fitting shirts with collars.
E. Wear fashionable scarves.
Answer: A. Create a communication system.
D. Try loose-fitting shirts with collars.
E. Wear fashionable scarves.
Explanation:
The client with a tracheostomy may be shy and hesitant to go out in public. The client should
have a sound communication method to ease frustration. The nurse can also suggest ways of

enhancing appearance so the client is willing to leave the house. These can include wearing
scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good
advice.
50. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors
does the nurse need to assess before teaching this particular client? (Select all that apply.)
A. Cognition
B. Dexterity
C. Hydration
D. Range of motion
E. Vision
Answer:
A. Cognition
B. Dexterity
D. Range of motion
E. Vision
Explanation:
The older adult is at risk for having impairments in cognition, dexterity, range of motion, and
vision that could limit the ability to perform tracheostomy care and should be assessed.
Hydration is not directly related to the ability to perform self-care.
51. A nurse is teaching a client about possible complications and hazards of home oxygen
therapy. About which complications does the nurse plan to teach the client? (Select all that
apply.)
A. Absorptive atelectasis
B. Combustion
C. Dried mucous membranes
D. Oxygen-induced hyperventilation
E. Toxicity
Answer:
A. Absorptive atelectasis

B. Combustion
C. Dried mucous membranes
E. Toxicity
Explanation:
Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous
membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.
52. A nurse assesses a client's electrocardiograph tracing and observes that not all QRS
complexes are preceded by a P wave. How should the nurse interpret this observation?
A. The client has hyperkalaemia causing irregular QRS complexes.
B. Ventricular tachycardia is overriding the normal atrial rhythm.
C. The client's chest leads are not making sufficient contact with the skin.
D. Ventricular and atrial depolarizations are initiated from different sites.
Answer: D. Ventricular and atrial depolarizations are initiated from different sites.
Explanation:
Normal rhythm shows one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a
different source of initiation of depolarization. This finding on an electrocardiograph tracing is
not an indication of hyperkalaemia, ventricular tachycardia, or disconnection of leads.
53. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse
symptoms. Which activity modification should the nurse suggest to avoid further slowing of the
heart rate?
A. "Make certain that your bath water is warm."
B. "Avoid straining while having a bowel movement."
C "Limit your intake of caffeinated drinks to one a day."
D "Avoid strenuous exercise such as running."
Answer: B. "Avoid straining while having a bowel movement."
Explanation:
Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which
stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not

desirable in a person who has bradycardia. The other instructions are not appropriate for this
condition.
54. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify
as being at greatest risk for atrial fibrillation?
A. A 45-year-old who takes an aspirin daily
B. A 50-year-old who is post coronary artery bypass graft surgery
C. A 78-year-old who had a carotid endarterectomy
D. An 80-year-old with chronic obstructive pulmonary disease
Answer: B. A 50-year-old who is post coronary artery bypass graft surgery
Explanation:
Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence
after coronary artery bypass graft surgery. The other conditions do not place these clients at
higher risk for atrial fibrillation.
55. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to
the possibility of a serious complication from this condition?
A. Sinus tachycardia
B. Speech alterations
C. Fatigue
D. Dyspnea with activity
Answer: B. Speech alterations
Explanation:
Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes
changes in mentation, speech, sensory function, and motor function. Clients with atrial
fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint.
Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output
caused by the rhythm disturbance.

56. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication
should the nurse expect to find on this client's medication administration record to prevent a
common complication of this condition?
A. Sotalol (Beta pace)
B. Warfarin (Coumadin)
C. Atropine (Sal-Tropine)
D. Lidocaine (Xylocaine)
Answer: B. Warfarin (Coumadin)
Explanation:
Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated
with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are
not appropriate for this complication.
57. A nurse administers prescribed adenosine (Aden card) to a client. Which response should the
nurse assess for as the expected therapeutic response?
A. Decreased intraocular pressure
B. Increased heart rate
C. Short period of asystole
D. Hypertensive crisis
Answer: C. Short period of asystole
Explanation:
Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension,
dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.
58. A telemetry nurse assesses a client with third-degree heart block who has wide QRS
complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the
nurse complete next?
A. Pulmonary auscultation
B. Pulse strength and amplitude
C. Level of consciousness
D. Mobility and gait stability

Answer: C. Level of consciousness
Explanation:
A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic
consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for
level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the
other assessments should be completed, the client's level of consciousness is the priority. A nurse
cares for a client with an intravenous temporary pacemaker for bradycardia.
59. The nurse observes the presence of a pacing spike but no QRS complex on the client's
electrocardiogram. Which action should the nurse take next?
A. Administer intravenous diltiazem (Cardizem).
B. Assess vital signs and level of consciousness.
C. Administer sublingual nitro-glycerine.
D. Assess capillary refill and temperature.
Answer: B. Assess vital signs and level of consciousness.
Explanation:
In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit
through the chest wall. The pacemaker spike should be followed immediately by a QRS
complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there
is no capture, then there is no ventricular depolarization and contraction. The nurse should assess
for cardiac output via vital signs and level of consciousness. The other interventions would not
determine if the client is tolerating the loss of capture.
60. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority
intervention should the nurse perform prior to defibrillating this client?
A. Make sure the defibrillator is set to the synchronous mode.
B. Administer 1 mg of intravenous epinephrine.
C. Test the equipment by delivering a smaller shock at 100 joules.
D. Ensure that everyone is clear of contact with the client and the bed.
Answer: D. Ensure that everyone is clear of contact with the client and the bed.
Explanation:

To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed
and ensures their compliance before delivery of the shock. A precordial thump can be delivered
when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment
should not be tested before a client is defibrillated because this is an emergency procedure;
equipment should be checked on a routine basis. Epinephrine should be administered after
defibrillation.
61. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
assesses the client's understanding. Which statement by the client indicates a correct
understanding of the teaching?
A. "I should wear a snug-fitting shirt over the ICD."
B. "I will avoid sources of strong electromagnetic fields."
C. "I should participate in a strenuous exercise program."
D "Now I can discontinue my antidysrhythmic medication."
Answer: B. "I will avoid sources of strong electromagnetic fields."
Explanation:
The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic
fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator.
The client should be encouraged to exercise but should not engage in strenuous activities that
cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge
inappropriately. The client should continue all prescribed medications.
62. A nurse cares for a client with atrial fibrillation who reports fatigue when completing
activities of daily living. What interventions should the nurse implement to address this client's
concerns?
A. Administer oxygen therapy at 2 Liters per nasal cannula.
B. Provide the client with a sleeping pill to stimulate rest.
C. Schedule periods of exercise and rest during the day.
D. Ask unlicensed assistive personnel to help bathe the client.
Answer: C. Schedule periods of exercise and rest during the day.
Explanation:

Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when
completing activities of daily living. The nurse should schedule periods of exercise and rest
during the day to decrease fatigue. The other interventions will not assist the client with self-care
activities.
63. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which
action should the nurse take prior to the initiation of cardioversion?
A. Administer intravenous adenosine.
B. Turn off oxygen therapy.
C. Ensure a tongue blade is available.
D. Position the client on the left side.
Answer: B. Turn off oxygen therapy.
Explanation:
For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The
other interventions are not appropriate for a cardioversion. The client should be placed in a spine
position.
64. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home
health care services. Which priority information should be communicated to the home health
nurse upon discharge?
A. Medication reconciliation
B. Immunization history
C. Religious beliefs
D. Nutrition preferences
Answer: A. Medication reconciliation
Explanation:
The home health nurse needs to know current medications the client is taking to ensure
assessment, evaluation, and further education related to these medications. The other information
will not assist the nurse to develop a plan of care for the client.

65. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate
intervention by the nurse?
A. Mid-sternal chest pain
B. Increased urine output
C. Mild orthostatic hypotension
D. P wave touching the T wave
Answer: A. Mid-sternal chest pain
Explanation:
Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial
workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace.
This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic
hypotension are not life-threatening conditions and therefore do not require immediate
intervention. The P wave touching the T wave indicates significant tachycardia and should be
assessed to determine the underlying rhythm and cause; this is an important assessment but is not
as critical as chest pain, which indicates cardiac cell death.
66. A nurse teaches a client who experiences occasional premature atrial contractions (PACs)
accompanied by palpitations that resolve spontaneously without treatment. Which statement
should the nurse include in this client's teaching?
A. "Minimize or abstain from caffeine."
B. "Lie on your side until the attack subsides."
C. "Use your oxygen when you experience PACs."
D. "Take amiodarone (Cardamone) daily to prevent PACs."
Answer: A. "Minimize or abstain from caffeine."
Explanation:
PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs,
the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress.
Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although
medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client
first should try lifestyle changes to control them.

67. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse.
The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? •
A. "Substance abuse puts clients at risk for many health issues."
B. "The hospital requires that I ask you about cocaine use."
C. "Clients who use cocaine are at risk for fatal dysrhythmias."
D. "We can provide services for cessation of substance abuse."
Answer: C. "Clients who use cocaine are at risk for fatal dysrhythmias."
Explanation:
Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal
dysrhythmias. The other responses do not adequately address the client's question.
68. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic
monitoring. Which statement should the nurse provide to the UAP related to this procedure?
A. "Clean the skin and clip hairs if needed."
B. "Add gel to the electrodes prior to applying them."
C. "Place the electrodes on the posterior chest."
D. "Turn off oxygen prior to monitoring the client."
Answer: A. "Clean the skin and clip hairs if needed."
Explanation:
To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes
should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on
electrocardiographic monitoring.
69. A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below:
How should the nurse document this client's ECG strip?
A. Ventricular tachycardia
B. Ventricular fibrillation
C. Sinus rhythm with premature atrial contractions (PACs)
D. Sinus rhythm with premature ventricular contractions (PVCs)
Answer: D. Sinus rhythm with premature ventricular contractions (PVCs)
Explanation:

Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization
that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation
rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions
initiated from another region of the atria before the sinus node initiates atrial depolarization.
70. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm
shown below: Which action should the nurse take first?
A. Assess airway, breathing, and level of consciousness.
B. Administer an amiodarone bolus followed by a drip.
C. Cardiovert the client with a biphasic defibrillator.
D. Begin cardiopulmonary resuscitation (CPR).
Answer: A. Assess airway, breathing, and level of consciousness.
Explanation:
Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus,
usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia.
The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code
Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation.
Amiodarone is the antidysrhythmic of choice, but it is not the first action.
71. A nurse performs an admission assessment on a 75-year-old client with multiple chronic
diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 Liters
per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the
reading shown below: Which action should the nurse take first?
A. Begin external temporary pacing.
B. Assess peripheral pulse strength.
C. Ask the client what medications he or she takes.
D. Administer 1 mg of atropine.
Answer: C. Ask the client what medications he or she takes.
Explanation:
This client is stable and therefore does not require any intervention except to determine the cause
of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple

chronic diseases are often on multiple medications that can interact with each other. The nurse
should assess the client's current medications first.
72. The nurse is caring for a client on the medical-surgical unit who suddenly becomes
unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for
assistance and a defibrillator, which action should the nurse take next?
A. Perform a pericardial thump.
B. Initiate cardiopulmonary resuscitation (CPR).
C. Start an 18-gauge intravenous line.
D. Ask the client's family about code status.
Answer: B. Initiate cardiopulmonary resuscitation (CPR).
Explanation:
The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with
immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse
should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client
does not already have an IV, other members of the team can insert one after defibrillation. The
client's code status should already be known by the nurse prior to this event. After assessing a
client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia,
the nurse documents the findings and compares these with the previous assessment findings:
Vital Signs Nursing
Assessment Time: 0800
Temperature: 98° F
Heart rate: 68 beats/min
Blood pressure: 135/60 mm Hg
Respiratory rate: 14 breaths/min
Oxygen saturation: 96%
Oxygen therapy: 2 L nasal cannula
Time: 1000
Temperature: 98.2° F
Heart rate: 50 beats/min

Blood pressure: 132/57 mm Hg
Respiratory rate: 16 breaths/min
Oxygen saturation: 95%
Oxygen therapy: 2 L nasal cannula
Time: 0800 Client alert and oriented.
Cardiac rhythm: normal sinus rhythm.
Skin: warm, dry, and appropriate for race.
Respirations equal and unlaboured.
Client denies shortness of breath and chest pain.
Time: 1000
Client alert and oriented.
Cardiac rhythm: sinus bradycardia.
Skin: warm, dry, and appropriate for race.
Respirations equal and unlaboured.
Client denies shortness of breath and chest pain.
Client voids 420 mL of clear yellow urine.
73. Based on the assessments, which action should the nurse take?
A. Stop the infusion and flush the IV.
B. Slow the amiodarone infusion rate.
C. Administer IV normal saline.
D. Ask the client to cough and deep breathe.
Answer: B. Slow the amiodarone infusion rate.
Explanation:
IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The
correct action for the nurse to take at this time is to slow the infusion, because the client is
asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the
medication could allow fatal dysrhythmias to occur. The administration of IV fluids and

encouragement of coughing and deep breathing exercises are not indicated, and will not increase
the client's heart rate.
74. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of
128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)
A. Decrease in cardiac output
B. Increase in cardiac output
C. Decrease in blood pressure
D. Increase in blood pressure
E. Decrease in urine output
F. Increase in urine output
Answer: A. Decrease in cardiac output
D. Increase in blood pressure
E. Decrease in urine output
Explanation:
Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to
increase. However, in a client who has congestive heart failure or a client with long-term
tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As
cardiac output and blood pressure decrease, urine output will fall
75. A nurse teaches a client with a new permanent pacemaker. Which instructions should the
nurse include in this client's teaching? (Select all that apply.)
A. "Until your incision is healed, do not submerge your pacemaker. Only take showers."
B. "Report any pulse rates lower than your pacemaker settings."
C. "If you feel weak, apply pressure over your generator."
D. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)."
E. "Do not lift your left arm above the level of your shoulder for 8 weeks."
Answer: A. "Until your incision is healed, do not submerge your pacemaker. Only take
showers."
B. "Report any pulse rates lower than your pacemaker settings."
E. "Do not lift your left arm above the level of your shoulder for 8 weeks."

Explanation:
The client should not submerge in water until the site has healed; after the incision is healed, the
client may take showers or baths without concern for the pacemaker. The client should be
instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker
setting or greater than 100 beats/min. The client should be advised of restrictions on physical
activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply
pressure over the generator and should avoid tight clothing. The client should never have MRI
because, whether turned on or off, the pacemaker contains metal. The client should be advised to
inform all health care providers that he or she has a pacemaker.
76. A nurse is teaching a client with premature ectopic beats. Which education should the nurse
include in this client's teaching? (Select all that apply.)
A. Smoking cessation
B. Stress reduction and management
C. Avoiding vagal stimulation
D. Adverse effects of medications
E. Foods high in potassium
Answer: A. Smoking cessation
B. Stress reduction and management
D. Adverse effects of medications
Explanation:
A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage
stress, take medications as prescribed, and report adverse effects of medications. Clients with
premature beats are not at risk for vasovagal attacks or potassium imbalances.
77. A nurse assesses a client who had a myocardial infarction and is hypotensive. Which
additional assessment finding should the nurse expect?
A. Heart rate of 120 beats/min
B. Cool, clammy skin
C. Oxygen saturation of 90%
D. Respiratory rate of 8 breaths/min

Answer: A. Heart rate of 120 beats/min
Explanation:
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease
in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the
sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is
an early response and is seen even when blood pressure is not critically low. An increased heart
rate and respiratory rate will compensate for the low blood pressure and maintain oxygen
saturations and perfusion. The client may not be able to compensate for long, and decreased
oxygenation and cool, clammy skin will occur later.
78. A nurse assesses a client after administering a prescribed beta blocker. Which assessment
should the nurse expect to find?
A. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
B. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
C. Oxygen saturation increased from 88% to 96%
D. Pulse decreased from 100 beats/min to 80 beats/min
Answer: D. Pulse decreased from 100 beats/min to 80 beats/min
Explanation:
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic
(fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR
and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2adrenergic receptor sites. Cardiac output will drop because of decreased HR.
79. A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as
having the greatest risk for cardiovascular disease?
A. An 86-year-old man with a history of asthma
B. A 32-year-old Asian-American man with colorectal cancer
C. A 45-year-old American Indian woman with diabetes mellitus
D. A 53-year-old postmenopausal woman who is on hormone therapy
Answer: C. A 45-year-old American Indian woman with diabetes mellitus
Explanation:

The incidence of coronary artery disease and hypertension is higher in American Indians than in
whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary
artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy
do not increase risk for cardiovascular disease.
80. A nurse assesses an older adult client who has multiple chronic diseases. The client's heart
rate is 48 beats/min. Which action should the nurse take first?
A. Document the finding in the chart.
B. Initiate external pacing.
C. Assess the client's medications.
D. Administer 1 mg of atropine
Answer: C. Assess the client's medications.
Explanation:
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in
bradycardia. The nurse should check the medication reconciliation for medications that might
cause such a drop in heart rate, then should inform the health care provider. Documentation is
important, but it is not the priority action. The heart rate is not low enough for atropine or an
external pacemaker to be needed.
81. An emergency room nurse obtains the health history of a client. Which statement by the
client should alert the nurse to the occurrence of heart failure?
A. "I get short of breath when I climb stairs."
B. "I see halos floating around my head."
C. "I have trouble remembering things."
D. "I have lost weight over the past month."
Answer: A. "I get short of breath when I climb stairs."
Explanation:
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity
such as stair climbing. The other findings are not specific to early occurrence of heart failure.

82. A nurse obtains the health history of a client who is newly admitted to the medical unit.
Which statement by the client should alert the nurse to the presence of edema?
A. "I wake up to go to the bathroom at night."
B. "My shoes fit tighter by the end of the day."
C. "I seem to be feeling more anxious lately."
D. "I drink at least eight glasses of water a day."
Answer: B. "My shoes fit tighter by the end of the day."
Explanation:
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema.
The nurse should note whether the client feels that his or her shoes or rings are tight, and should
observe, when present, an indentation around the leg where the socks end. The other answers do
not describe edema.
83. A nurse assesses an older adult client who is experiencing a myocardial infarction. Which
clinical manifestation should the nurse expect?
A. Excruciating pain on inspiration
B. Left lateral chest wall pain
C. Disorientation and confusion
D. Numbness and tingling of the arm
Answer: C. Disorientation and confusion
Explanation:
In older adults, disorientation or confusion may be the major manifestation of myocardial
infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the
arm could also be related to the myocardial infarction. However, the nurse should be more
concerned about the new onset of disorientation or confusion caused by decreased perfusion.
84. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The
nurse notes that the left pedal pulse is weak. Which action should the nurse take?
A. Elevate the leg and apply a sandbag to the entrance site.
B. Increase the flow rate of intravenous fluids.
C. Assess the colour and temperature of the left leg.

D. Document the finding as "left pedal pulse of +1/4."
Answer: C. Assess the colour and temperature of the left leg.
Explanation:
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial
obstruction. The pulse may be faint because of edema. The left pulse should be compared with
the right, and pulses should be compared with previous assessments, especially before the
procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease
in circulation. Once all peripheral and vascular assessment data are acquired, the primary health
care provider should be notified. Simply documenting the findings is inappropriate. The leg
should be positioned below the level of the heart or dangling to increase blood flow to the distal
portion of the leg. Increasing intravenous fluids will not address the client's problem.
85. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which
assessment finding requires immediate intervention?
A. Urinary output less than intake
B. Bruising at the insertion site
C. Slurred speech and confusion
D. Discomfort in the left leg
Answer: C. Slurred speech and confusion
Explanation:
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident.
A change in neurologic status needs to be acted on immediately. Discomfort and bruising are
expected at the site. If intake decreases, a client can become dehydrated because of dye
excretion. The second intervention would be to increase the client's fluid status. Neurologic
changes would take priority.
86. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment
should the nurse complete prior to this procedure?
A. Client's level of anxiety
B. Ability to turn self in bed
C. Cardiac rhythm and heart rate

D. Allergies to iodine-based agents
Answer: D. Allergies to iodine-based agents
Explanation:
Before the procedure, the nurse should ascertain whether the client has an allergy to iodinecontaining preparations, such as seafood or local anaesthetics. The contrast medium used during
the procedure is iodine based. This allergy can cause a life- threatening reaction, so it is a high
priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac
status.
87. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart.
The client's health history includes a previous myocardial infarction and pacemaker implantation.
Which action should the nurse take?
A. Schedule an electrocardiogram just before the MRI.
B. Notify the health care provider before scheduling the MRI.
C. Call the physician and request a laboratory draw for cardiac enzymes.
D. Instruct the client to increase fluid intake the day before the MRI.
Answer: B. Notify the health care provider before scheduling the MRI.
Explanation:
The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health
care provider and report that the client has a pacemaker so the provider can order other
diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased
fluids.
88. A nurse assesses a client who is recovering from a myocardial infarction. The client's
pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
A. Compare the results with previous pulmonary artery pressure readings.
B. Increase the intravenous fluid rate because these readings are low.
C. Immediately notify the health care provider of the elevated pressures.
D. Document the finding in the client's chart as the only action.
Answer: A. Compare the results with previous pulmonary artery pressure readings.
Explanation:

Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15
mm Hg for diastolic. Although this client's readings are within normal limits, the nurse needs to
assess any trends that may indicate a need for medical treatment to prevent complications. There
is no need to increase intravenous fluids or notify the provider.
89. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is
scheduled for bypass surgery. Which intervention should the nurse be prepared to implement
while this client waits for surgery?
A. Administration of IV furosemide (Lasix)
B. Initiation of an external pacemaker
C. Assistance with endotracheal intubation
D. Placement of central venous access
Answer: B. Initiation of an external pacemaker
Explanation:
The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle,
and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the
client totally occludes the RCA, the AV node would not function and the client would go into
heart block, so emergency pacing should be available for the client. Furosemide, intubation, and
central venous access will not address the primary complication of RCA occlusion, which is AV
node malfunction.
90. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high
risk for coronary artery disease. Which statement related to nutrition should the nurse include in
this client's teaching?
A. "The best way to lose weight is a high-protein, low-carbohydrate diet."
B. "You should balance weight loss with consuming necessary nutrients."
C. "A nutritionist will provide you with information about your new diet."
D. "If you exercise more frequently, you won't need to change your diet."
Answer: B. "You should balance weight loss with consuming necessary nutrients."
Explanation:

Clients at risk for cardiovascular diseases should follow the American Heart Association
guidelines to combat obesity and improve cardiac health. The nurse should encourage the client
to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing
weight. High-protein food items are often high in fat and calories. Although the nutritionist can
assist with client education, the nurse should include nutrition education and assist the client to
make healthy decisions. Exercising and eating nutrient-rich foods are both important components
in reducing cardiovascular risk.
91. A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble
sleeping at night." How should the nurse respond?
A. "I will consult the provider to prescribe a sleep study to determine the problem."
B. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help."
C. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at
night."
D. "Use pillows to elevate your head and chest while you are sleeping."
Answer: D. "Use pillows to elevate your head and chest while you are sleeping."
Explanation:
The client is experiencing orthopnoea (shortness of breath while lying flat). The nurse should
teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is
not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnoea.
92. A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I
will need to stop eating so much chili to keep that indigestion pain from returning." How should
the nurse respond?
A. "Chili is high in fat and calories; it would be a good idea to stop eating it."
B. "The provider has prescribed an antacid for you to take every morning."
C. "What do you understand about what happened to you?"
D. "When did you start experiencing this indigestion?"
Answer: C. "What do you understand about what happened to you?"
Explanation:

Clients who experience myocardial infarction often respond with denial, which is a defense
mechanism. The nurse should ask the client what he or she thinks happened, or what the illness
means to him or her. The other responses do not address the client's misconception about recent
pain and the cause of that pain.
93. A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am
afraid I might die." How should the nurse respond?
A. "This is a routine surgery and the risk of death is very low."
B. "Would you like to speak with a chaplain prior to surgery?"
C. "Tell me more about your concerns about the surgery."
D. "What support systems do you have to assist you?"
Answer: C. "Tell me more about your concerns about the surgery."
Explanation:
The nurse should discuss the client's feelings and concerns related to the surgery. The nurse
should not provide false hope or push the client's concerns off on the chaplain. The nurse should
address support systems after addressing the client's current issue.
94. An emergency department nurse triages clients who present with chest discomfort. Which
client should the nurse plan to assess first?
A. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers
B. A 49-year-old male who reports moderate pain that is worse on inspiration
C. A 53-year-old female who reports substernal pain that radiates to her abdomen
D. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
Answer: D. A 58-year-old male who describes his pain as intense stabbing that spreads across
his chest
Explanation:
All clients who have chest pain should be assessed more thoroughly. To determine which client
should be seen first, the nurse must understand common differences in pain descriptions. Intense
stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck
is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent
cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that

gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to
the abdomen is often associated with an esophageal-gastric problem, especially when this pain is
experienced by a male client. Female clients may experience abdominal discomfort with a
myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric
problems should be seen, they are not a higher priority than myocardial infarction.
95. A nurse auscultated heart tones on an older adult client. Which action should the nurse take
based on heart tones heard? (Click the media button to hear the audio clip.)
A. Administer a diuretic.
B. Document the finding.
C. Decrease the IV flow rate.
D. Evaluate the client's medications
Answer: B. Document the finding.
Explanation:
The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a
stiffened ventricle. The nurse should document the finding, but no other intervention is needed at
this time.
96. A nurse assesses a client who has aortic regurgitation. In which location in the illustration
shown below should the nurse auscultate to best hear a cardiac murmur related to aortic
regurgitation?
A. Location A
B. Location B
C. Location C
D. Location D
Answer: A. Location A
Explanation:
The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

97. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a
cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select
all that apply.)
A. Assess for allergies to iodine.
B. Administer intravenous fluids.
C. Assess blood urea nitrogen (BUN) and creatinine results.
D. Insert a Foley catheter.
E. Administer a prophylactic antibiotic.
F. Insert a central venous catheter.
Answer: A. Assess for allergies to iodine.
B. Administer intravenous fluids.
C. Assess blood urea nitrogen (BUN) and creatinine results.
Explanation:
If the client has kidney disease (as indicated by BUN and creatinine results), fluids and
Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client
should be assessed for allergies to iodine, including shellfish; the contrast medium used during
the catheterization contains iodine. A Foley catheter and central venous catheter are not required
for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics
are not administered prior to a cardiac catheterization.
98. An emergency room nurse assesses a female client. Which assessment findings should alert
the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
A. Hypertension
B. Fatigue despite adequate rest
C. Indigestion
D. Abdominal pain
E. Shortness of breath
Answer: B. Fatigue despite adequate rest
C. Indigestion
E. Shortness of breath
Explanation:

Women may not have chest pain with myocardial infarction, but may feel discomfort or
indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal
fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath.
Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and
abdominal pain are not associated with acute coronary syndrome.
99. A nurse assesses a client who is recovering after a coronary catheterization. Which
assessment findings in the first few hours after the procedure require immediate action by the
nurse? (Select all that apply.)
A. Blood pressure of 140/88 mm Hg
B. Serum potassium of 2.9 mEq/L
C. Warmth and redness at the site
D. Expanding groin hematoma
E. Rhythm changes on the cardiac monitor
Answer: B. Serum potassium of 2.9 mEq/L
D. Expanding groin hematoma
E. Rhythm changes on the cardiac monitor
Explanation:
In the first few hours post procedure, the nurse monitors for complications such as bleeding from
the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalaemia, and
dysrhythmias. The client's blood pressure is slightly elevated but does not need immediate
action. Warmth and redness at the site would indicate an infection, but this would not be present
in the first few hours.
100. A nurse reviews a client's laboratory results. Which findings should alert the nurse to the
possibility of atherosclerosis? (Select all that apply.)
A. Total cholesterol: 280 mg/dL
B. High-density lipoprotein cholesterol: 50 mg/dL
C. Triglycerides: 200 mg/dL
D. Serum albumin: 4 g/dL
E. Low-density lipoprotein cholesterol: 160 mg/Dl

Answer: A. Total cholesterol: 280 mg/dL
C. Triglycerides: 200 mg/dL
E. Low-density lipoprotein cholesterol: 160 mg/Dl
Explanation:
A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and
low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular
disease. High-density lipoprotein cholesterol is within the normal range for both males and
females. Serum albumin is not assessed for atherosclerosis.
101. A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should
the nurse take when preparing this client for the procedure? (Select all that apply.)
A. Assist the provider to place a central venous access device.
B. Prepare for continuous blood pressure and pulse monitoring.
C. Administer the client's prescribed beta blocker.
D. Give the client nothing by mouth 3 to 6 hours before the procedure.
E. Explain to the client that dobutamine will simulate exercise for this examination.
Answer: B. Prepare for continuous blood pressure and pulse monitoring.
D. Give the client nothing by mouth 3 to 6 hours before the procedure.
E. Explain to the client that dobutamine will simulate exercise for this examination.
Explanation:
Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and
continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to
the procedure. Education about dobutamine, which will be administered during the procedure,
should be performed. Beta blockers are often held prior to the procedure.
102. A nurse cares for a client who is recovering from a right-sided heart catheterization. For
which complications of this procedure should the nurse assess? (Select all that apply.)
A. Thrombophlebitis
B. Stroke
C. Pulmonary embolism
D. Myocardial infarction

E. Cardiac tamponade
Answer: A. Thrombophlebitis
C. Pulmonary embolism
D. Myocardial infarction
E. Cardiac tamponade
Explanation:
When caring for a client recovering from a right-sided heart catheterization, the nurse should
assess for several potential complications. Thrombophlebitis (option A) can occur at the site of
catheter insertion due to irritation or injury to the vein. Pulmonary embolism (option C) is a risk
because the procedure involves manipulation of catheters within the venous system, which can
dislodge thrombi that may then travel to the pulmonary circulation. Myocardial infarction
(option D) is a possible complication due to the stress on the heart during the procedure. Cardiac
tamponade (option E) is another serious complication that can occur if bleeding occurs into the
pericardial sac, compressing the heart and impairing its ability to function. While stroke (option
B) is a potential complication of cardiac catheterization, it is more commonly associated with
left-sided procedures rather than right-sided ones.
103. A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at
greatest risk for the development of left-sided heart failure?
A. A 36-year-old woman with aortic stenosis
B. A 42-year-old man with pulmonary hypertension
C. A 59-year-old woman who smokes cigarettes daily
D. A 70-year-old man who had a cerebral vascular accident
Answer: A. A 36-year-old woman with aortic stenosis
Explanation:
A 36 year old woman with aortic stenosis Although most people with heart failure will have
failure that progresses from left to right, it is possible to have left-sided failure alone for a short
period. It is also possible to have heart failure that progresses from right to left. Causes of left
ventricular failure include mitral or aortic valve disease, coronary artery disease, and
hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right
ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

104. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the
possibility of left sided heart failure?
A. "I have been drinking more water than usual."
B. "I am awakened by the need to urinate at night."
C. "I must stop halfway up the stairs to catch my breath."
D. "I have experienced blurred vision on several occasions."
Answer: C. " I must stop halfway up the stairs to catch my breath "
Explanation:
Clients with left-sided heart failure report weakness or fatigue while performing normal activities
of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid
moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred
vision are not related to heart failure.
105. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts
the nurse to the possibility of right sided heart failure?
A. "I sleep with four pillows at night."
B. "My shoes fit really tight lately."
C. "I wake up coughing every night."
D. "I have trouble catching my breath."
Answer: B. "My shoes fit really tight lately."
Explanation:
Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure
builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms
include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results
of left-sided heart failure.
106. While assessing a client on a cardiac unit, a nurse identifies the presence of a S3 gallop.
Which action should the nurse take?
A. Assess for symptoms of left-sided heart failure.
B. Document this as a normal finding.

C. Call the health care provider immediately.
D. Transfer the client to the intensive care unit.
Answer: A. Assess for symptoms of left-sided heart failure.
Explanation:
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left
ventricular pressure and left ventricular failure. The other actions are not warranted.
107. A nurse cares for a client with right sided heart failure. The client asks, " Why do I need to
weigh myself every day? " How should the nurse respond?
A. "Weight is the best indication that you are gaining or losing fluid."
B. "Daily weights will help us make sure that you're eating properly."
C. "The hospital requires that all inpatients be weighed daily."
D. "You need to lose weight to decrease the incidence of heart failure." "
Answer: A. "Weight is the best indication that you are gaining or losing fluid."
Explanation:
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2
pounds. The other responses do not address the importance of monitoring fluid retention or loss.
108. A nurse is teaching a client with heart failure who has been prescribed enalapril ( Vasotec ).
Which statement should the nurse included in this client's teaching?
A. "Avoid using salt substitutes."
B. "Take your medication with food."
C. "Avoid using aspirin-containing products."
D. "Check your pulse daily."
Answer: A. "Avoid using salt substitutes."
Explanation:
Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of
potassium. Hyperkalaemia can be a life- threatening side effect, and clients should be taught to
limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do
not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often
prescribed in conjunction with ACE inhibitors and is not contraindicated.

109. After administering newly prescribed captopril ( Capoten ) to a client with heart failure, the
nurse implements interventions to decrease complications. Which priority intervention should the
nurse implement for this client?
A. Provide food to decrease nausea and aid in absorption.
B. Instruct the client to ask for assistance when rising from bed.
C. Collaborate with unlicensed assistive personnel to bathe the client.
D. Monitor potassium levels and check for symptoms of hypokalaemia.
Answer: B. Instruct the client to ask for assistance when rising from bed.
Explanation:
Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often
associated with hypotension, usually termed first-dose effect. The nurse should instruct the client
to seek assistance before arising from bed to prevent injury from postural hypotension. ACE
inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to
provide hygiene is not a priority. The client should be encouraged to complete activities of daily
living as independently as possible. The nurse should monitor for hyperkalemia, not
hypokalemia, especially if the client has renal insufficiency secondary to heart failure.
110. A nurse assesses a client after administering isosorbide mononitrate ( lmdur ). The client
reports a headache. Which action should the nurse take?
A. Initiate oxygen therapy.
B. Hold the next dose of Imdur.
C. Instruct the client to drink water.
D. Administer PRN acetaminophen.
Answer: D. Administer PRN acetaminophen.
Explanation:
The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches
during the initial period of therapy. Clients should be told about this side effect and encouraged
to take the medication with food. Some clients obtain relief with mild analgesics, such as
acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, these

interventions would not help. The client needs to take the medication as prescribed to prevent
angina; the medication should not be held.
111. A nurse teaches a client who is prescribed digoxin ( Lanoxin ) therapy. Which statement
should the nurse include in this client's teaching?
A. "Avoid taking aspirin or aspirin-containing products."
B. "Increase your intake of foods that are high in potassium."
C. "Hold this medication if your pulse rate is below 80 beats/min."
D. "Do not take this medication within 1 hour of taking an antacid."
Answer: D. "Do not take this medication within 1 hour of taking an antacid."
Explanation:
Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere
with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80
beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin
absorption, nor do these statements decrease complications of digoxin therapy.
112. A nurse teaches a client who has a history of heart failure. Which statement should the nurse
included in this client's discharge teaching?
A. "Avoid drinking more than 3 quarts of liquids each day."
B. "Eat six small meals daily instead of three larger meals."
C. "When you feel short of breath, take an additional diuretic."
D. "Weigh yourself daily while wearing the same amount of clothing."
Answer: D. "Weigh yourself daily while wearing the same amount of clothing."
Explanation:
Clients with heart failure are instructed to weigh themselves daily to detect worsening heart
failure early, and thus avoid complications. Other signs of worsening heart failure include
increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases
symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake
and output to prevent dehydration and overload, and take medications as prescribed. The most
important discharge teaching is daily weights as this provides the best data related to fluid
retention.

113. A nurse admits a client who is experiencing an exacerbation of heart failure. Which action
should the nurse take first?
A. Assess the client's respiratory status.
B. Draw blood to assess the client's serum electrolytes.
C. Administer intravenous furosemide (Lasix).
D. Ask the client about current medications.
Answer: A. Assess the client's respiratory status.
Explanation:
Assessment of respiratory and oxygenation status is the priority nursing intervention for the
prevention of complications. Monitoring electrolytes, administering diuretics, and asking about
current medications are important but do not take priority over assessing respiratory status.
114. A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert
the nurse to the possibility that the client's stenosis has progressed?
A. Oxygen saturation of 92%
B. Dyspnea on exertion
C. Muted systolic murmur
D. Upper extremity weakness
Answer: B. Dyspnea on exertion
Explanation:
Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs
increases. The other manifestations do not relate to the progression of mitral valve stenosis.
115. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client
asks, " Why will I need to take anticoagulants for the rest of my life? " How should the nurse
respond?
A. "The prosthetic valve places you at greater risk for a heart attack."
B. "Blood clots form more easily in artificial replacement valves."
C. "The vein taken from your leg reduces circulation in the leg."
D. "The surgery left a lot of small clots in your heart and lungs."

Answer: B. "Blood clots form more easily in artificial replacement valves."
Explanation:
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate
easily and initiate the formation of blood clots. The other responses are inaccurate.
116. After teaching a client who is being discharged home after mitral valve replacement surgery,
the nurse assesses the client's understanding. Which client statement indicates a need for
additional teaching?
A. "I'll be able to carry heavy loads after 6 months of rest."
B. "I will have my teeth cleaned by my dentist in 2 weeks."
C. "I must avoid eating foods high in vitamin K, like spinach."
D. "I must use an electric razor instead of a straight razor to shave."
Answer: B. "I will have my teeth cleaned by my dentist in 2 weeks."
Explanation:
Clients who have defective or repaired valves are at high risk for endocarditis. The client who
has had valve surgery should avoid dental procedures for 6 months because of the risk for
endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed
on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on
anticoagulant therapy should be instructed on bleeding precautions, including using an electric
razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients
recovering from open heart valve replacements should not carry anything heavy for 6 months
while the chest incision and muscle heal.
117. A nurse cares for a client with infective endocarditis. Which infection control precautions
should the nurse use?
A. Standard Precautions
B. Bleeding precautions
C. Reverse isolation
D. Contact isolation
Answer: A. Standard Precautions
Explanation:

The client with infective endocarditis does not pose any specific threat of transmitting the
causative organism. Standard Precautions should be used. Bleeding precautions or reverse or
contact isolation is not necessary.
118. A nurse assesses a client with pericarditis. Which assessment finding should the nurse
expect to find?
A. Heart rate that speeds up and slows down
B. Friction rub at the left lower sternal border
C. Presence of a regular gallop rhythm
D. Coarse crackles in bilateral lung bases
Answer: B. Friction rub at the left lower sternal border
Explanation:
The client with pericarditis may present with a pericardial friction rub at the left lower sternal
border. This sound is the result of friction from inflamed pericardial layers when they rub
together. The other assessments are not related.
119. After teaching a client who is recovering from a heart transplant to change positions slowly,
the client asks " Why is this important? How should the nurse respond?
A. "Rapid position changes can create shear and friction forces, which can tear out your internal
vascular sutures."
B. "Your new vascular connections are more sensitive to position changes, leading to increased
intravascular pressure and dizziness."
C. "Your new heart is not connected to the nervous system and is unable to respond to decreases
in blood pressure caused by position changes."
D. "While your heart is recovering, blood flow is diverted away from the brain, increasing the
risk for stroke when you stand up."
Answer: C. "Your new heart is not connected to the nervous system and is unable to respond to
decreases in blood pressure caused by position changes."
Explanation:
Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for
blood pressure drops caused by position changes do not function. This allows orthostatic

hypotension to persist in the postoperative period. The other options are false statements and do
not correctly address the client's question.
120. A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine
( Sand immune ). Which statement should the nurse include in the client's discharge teaching?
A. "Use a soft-bristled toothbrush and avoid flossing."
B. "Avoid large crowds and people who are sick."
C. "Change positions slowly to avoid hypotension."
D. "Check your heart rate before taking the medication."
Answer: B. "Avoid large crowds and people who are sick."
Explanation:
These agents cause immune suppression, leaving the client more vulnerable to infection. The
medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in
heart rate.
121. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The
client appears depressed and states, " I know a transplant is my last chance, but I don't want to
become a vegetable." How should the nurse respond?
A. "Would you like to speak with a priest or chaplain?"
B. "I will arrange for a psychiatrist to speak with you."
C. "Do you want to come off the transplant list?"
D. "Would you like information about advance directives?"
Answer: D. "Would you like information about advance directives?"
Explanation:
The client is verbalizing a real concern or fear about negative outcomes of the surgery. This
anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic
stimulation. The best action is to allow the client to verbalize the concern and work toward a
positive outcome without making the client feel as though he or she is crazy. The client needs to
feel that he or she has some control over the future. The nurse personally provides care to
address the client's concerns instead of pushing the client's issues off on a chaplain or

psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the
transplant list, which is the best treatment option.
122. A nurse assesses a client who has a history of heart failure. Which question should the nurse
ask to assess the extent of the client's heart failure?
A. "Do you have trouble breathing or chest pain?"
B. "Are you able to walk upstairs without fatigue?"
C. "Do you awake with breathlessness during the night?"
D. "Do you have new-onset heaviness in your legs?"
Answer: B. "Are you able to walk upstairs without fatigue?"
Explanation:
Clients with a history of heart failure generally have negative findings, such as shortness of
breath. The nurse needs to determine whether the client's activity is the same or worse, or
whether the client identifies a decrease in activity level. Trouble breathing, chest pain,
breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide
data that can determine the extent of the client's heart failure.
123. A nurse cares for an older adult client with heart failure. The client states, " I don't know
what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die
" How should the nurse respond?
A. "Would you like to talk more about this?"
B. "You are lucky to have such a devoted daughter."
C. "It is normal to feel as though you are a burden."
D. "Would you like to meet with the chaplain?"
Answer: A. "Would you like to talk more about this?"
Explanation:
Depression can occur in clients with heart failure, especially older adults. Having the client talk
about his or her feelings will help the nurse focus on the actual problem. Open-ended statements
allow the client to respond safely and honestly. The other options minimize the client's concerns
and do not allow the nurse to obtain more information to provide client-centered care

124. A nurse teaches a client with heart failure about energy conservation. Which statement
should the nurse include in this client's teaching?
A. "Walk until you become short of breath, and then walk back home."
B. "Gather everything you need for a chore before you begin."
C. "Pull rather than push or carry items heavier than 5 pounds."
D. "Take a walk after dinner every day to build up your strength."
Answer: B. "Gather everything you need for a chore before you begin."
Explanation:
A client who has heart failure should be taught to conserve energy. Gathering all supplies needed
for a chore at one time decreases the amount of energy needed. The client should not walk until
becoming short of breath because he or she may not make it back home. Pushing a cart takes less
energy than pulling or lifting. Although walking after dinner may help the client, the nurse
should teach the client to complete activities when he or she has the most energy. This is usually
in the morning.
125. A nurse is caring with acute pericarditis who reports substenal precordial pain that radiates
to the left side of the neck. Which nonpharmacologic comfort measure should the nurse
implement?
A. Apply an ice pack to the client's chest.
B. Provide a neck rub, especially on the left side.
C. Allow the client to lie in bed with the lights down.
D. Sit the client up with a pillow to lean forward on.
Answer: D. Sit the client up with a pillow to lean forward on.
Explanation:
Pain from acute pericarditis may worsen when the client lays supine. The nurse should position
the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is
decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will
not relieve this pain.
126. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia
should the nurse assess?

A. Pre ventricular contractions
B. Atrial fibrillation
C. Symptomatic bradycardia
D. Sinus tachycardia
Answer: B. Atrial fibrillation
Explanation:
Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis.
Preventricular contractions and bradycardia are not associated with valvular problems. These are
usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node
problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac
output.
127. A nurse is assessing a client with left sided heart failure. For which clinical manifestations
should the nurse assess?(Select all that apply.)
A. Pulmonary crackles
B. Confusion, restlessness
C. Pulmonary hypertension
D. Dependent edema
E. Cough that worsens at night
Answer: A. Pulmonary crackles
B. Confusion, restlessness
E. Cough that worsens at night
Explanation:
Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in
afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure
occurs with problems from the pulmonary vasculature onward including pulmonary
hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.
128. A nurse evaluates laboratory results for a client with heart failure. Which results should the
nurse expect?(Select all that apply.)
A. Haematocrit: 32.8%

B. Serum sodium: 130 mEq/L
C. Serum potassium: 4.0 mEq/L
D. Serum creatinine: 1.0 mg/dL
E. Proteinuria
F. Microalbuminuria Haematocrit: 32.8%
Answer: A. Hematocrit: 32.8%
B. Serum sodium: 130 mEq/L
E. Proteinuria
F. Microalbuminuria Hematocrit: 32.8%
Explanation:
A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to
fluid. A serum sodium of 130 mEq/L is low because of haemodilution. Microalbuminuria and
proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of
decreased compliance of the heart. The potassium level is on the high side of normal and the
serum creatinine level is normal.
129. A nurse assesses client on a cardiac unit. Which client should the nurse identify as at
greatest risk for the development of acute pericarditis?(Select all that apply.)
A. A 36-year-old woman with systemic lupus erythematosus (SLE)
B. A 42-year-old man recovering from coronary artery bypass graft surgery
C. A 59-year-old woman recovering from a hysterectomy
D. An 80-year-old man with a bacterial infection of the respiratory tract
E. An 88-year-old woman with a stage III sacral ulcer
Answer: A. A 36-year-old woman with systemic lupus erythematosus (SLE)
B. A 42-year-old man recovering from coronary artery bypass graft surgery
D. An 80-year-old man with a bacterial infection of the respiratory tract
Explanation:
Acute pericarditis is most commonly associated acute exacerbations of systemic connective
tissue disease, including SLE; with Dressler's syndrome, or inflammation of the cardiac sac after
cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial,

viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not
increase clients' risk for acute pericarditis.
130. After teaching a client with congestive heart failure ( CHF ), the nurse assesses the client's
understanding. Which statement indicates a correct understanding of the teaching related to
nutritional intake?(Select all that apply.)
A. "I'll read the nutritional labels on food items for salt content."
B. "I will drink at least 3 Liters of water each day."
C. "Using salt in moderation will reduce the workload of my heart."
D. "I will eat oatmeal for breakfast instead of ham and eggs."
E. "Substituting fresh vegetables for canned ones will lower my salt intake."
Answer: A. "I'll read the nutritional labels on food items for salt content."
D. "I will eat oatmeal for breakfast instead of ham and eggs."
E. "Substituting fresh vegetables for canned ones will lower my salt intake."
Explanation:
Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to
decrease the workload of the heart. The client should be taught to read nutritional labels on all
food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit
water intake to a normal 2 L/day.
131. A nurse collaborates with an unlicensed assistive personnel to provide care for a client with
congestive heart failure. Which instructions should the nurse provide to the UPA when delegating
care for this client?(Select all that apply.)
A. "Reposition the client every 2 hours."
B. "Teach the client to perform deep-breathing exercises."
C. "Accurately record intake and output."
D. "Use the same scale to weigh the client each morning."
E. "Place the client on oxygen if the client becomes short of breath."
Answer: A. "Reposition the client every 2 hours."
C. "Accurately record intake and output."
D. "Use the same scale to weigh the client each morning."

Explanation:
The UAP should reposition the client every 2 hours to improve oxygenation and prevent
atelectasis. The UAP can also accurately record intake and output, and use the same scale to
weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess
the need for and provide oxygen therapy.
132. A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core
Measure Set, which actions should the nurse complete prior to discharging this client? Select all
that apply.)
A. Teach the client about dietary restrictions.
B. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor.
C. Encourage the client to take a baby aspirin each day.
D. Confirm that an echocardiogram has been completed.
E. Consult a social worker for additional resources.
Answer: A. Teach the client about dietary restrictions.
Explanation:
Ensure the client is prescribed an antiotensin-converting enzyme ( ACE ) inhibitor.
The Heart Failure Core Measure Set includes discharge instructions on diet, activity,
medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular
systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or
angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is
usually prescribed for clients who experience a myocardial infarction. Although the nurse may
consult the social worker or case manager for additional resources, this is not part of the Core
Measures.
133. A nurse prepares to discharge a client who has heart failure. Which questions should the
nurse ask to ensure this client's safety prior to discharging home?
A. "Are your bedroom and bathroom on the first floor?"
B. "What social support do you have at home?"
C. "Will you be able to afford your oxygen therapy?"
D. "What spiritual beliefs may impact your recovery?"

E. "Are you able to accurately weigh yourself at home?"
Answer: A. " Are your bedroom and bathroom on the first floor "
B. " What social support do you have at home? "
D. " What spiritual beliefs may impact your recovery? "
Explanation:
To ensure safety upon discharge, the nurse should assess for structural barriers to functional
ability, such as stairs. The nurse should also assess the client's available social support, which
may include family, friends, and home health services. The client's ability to adhere to
medication and treatments, including daily weights, should also be reviewed. The other questions
do not address the client's safety upon discharge.
134. A nurse assesses a client who is recovering from a heart transplant. Which assessment
findings should alert the nurse to the possibility of heart transplant rejection?(Select all that
apply.)
A. Shortness of breath
B. Abdominal bloating
C. New-onset bradycardia
D. Increased ejection fraction
E. Hypertension
Answer: A. Shortness of breath
B. Abdominal bloating
C. New-onset bradycardia
Explanation:
Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid
gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter,
decreased activity tolerance, and decreased ejection fraction.
135. A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment
findings should the nurse expect?(Select all that apply.)
A. Weight gain
B. Night sweats

C. Cardiac murmur
D. Abdominal bloating
E. Osler's nodes Night sweats
F. Cardiac murmur Osler's nodes
Answer: C. Cardiac murmur
E. Osler's nodes Night sweats
F. Cardiac murmur Osler's nodes
Explanation:
Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise
and fatigue, anorexia and weight loss, cardiac murmur, and Osler's nodes on palms of the hands
and soles of the feet. Abdominal bloating is a manifestation of heart transplantation rejection.