1.

A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a
diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago.
Which of the following cardiac enzymes would confirm the infarction occurred 14 days
ago? - Troponin T
2. A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1
aspirin per day. Which of the following is an appropriate response by the nurse? - Aspirin
reduces the formation of blood clots that could cause a heart attack.
3. A nurse is instructing a client who has angina about a new prescription for metoprolol.
Which of the following statements by the client indicates understanding of the teaching?
- "I will call my doctor if my pulse rate is less than 60."
4. A nurse is presenting a community education program on recommended lifestyle
changes to prevent angina and myocardial infarction. Which of the following changes
should the nurse recommend be made first? - smoking cessation
5. A nurse is caring for a client who has heart failure and reports increased shortness of
breath. The nurse increases the oxygen per protocol. Which of the following actions
should the nurse take first? - Assist the client into a high-Fowler's position.
6. A nurse is caring for a client who has heart failure and asks how to limit fluid intake to
2,000 mL/day. Which of the following is an appropriate response by the nurse? - "Pour
the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you
drink."
7. A nurse is teaching a client who has heart failure about the need to limit sodium in the
diet to 2,000 mg daily. Which of the following foods should be consumed in limited
quantities? (Select all that apply.) cheddar cheese, 2 oz, hot dog, canned tuna 3 oz,
baked ham.
8. A nurse is completing discharge teaching to a client who has heart failure and is
encouraged to increase potassium in his diet. Which of the following statements by the
client indicates understanding of the teaching? “I will eat more baked potatoes”
9. A nurse is completing the admission assessment of a client who has suspected
(cardiogenic) pulmonary edema. Which of the following are expected findings? (Select
all that apply.) - tachypnea, persistent cough, orthopnea
10. A nurse is screening a client for hypertension. Which of the following actions by the client
increase his risk for hypertension? (Select all that apply.) - Eating popcorn at the movie
theater, Consuming 36 oz of beer daily.
11. A nurse is caring for a client who is admitted to the emergency department with a blood
pressure of 266/147 mmHg. The client reports a headache and states that she is seeing
double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and
she has not been able to purchase more. Which of the following nursing interventions
should the nurse expect to perform first? - Obtain IV access and prepare to administer
an IV antihypertensive.
12. A nurse is providing discharge teaching for a client who has a prescription for furosemide
(Lasix) 40 mg PO daily. What time of day should the nurse encourage the client to take
this medication? - morning
13. A nurse is caring for a client who is admitted to the emergency department with a blood
pressure of 266/147 mmHg. The client reports a headache and states that she is seeing
double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and
she has not been able to purchase more. Which of the following nursing interventions
should the nurse expect to perform first? - Obtain IV access and prepare to administer
an IV antihypertensive.
14. A nurse is providing discharge teaching for a client who has a prescription for furosemide
(Lasix) 40 mg PO daily. What time of day should the nurse encourage the client to take
this medication? - morning
15. A nurse is caring for a client who has a new diagnosis of hypertension and a new
prescription for spironolactone (Aldactone) 25 mg/day. Which of the following statements
by the client indicates a need for further teaching? - "I should eat a lot of fruits and
vegetables, especially bananas and potatoes."
16. A nurse is caring for a client and reviewing a new prescription for an afterload-reducing
medication. The nurse should recognize that this medication is administered for which of
the following types of shock? - Cardiogenic
17. A nurse is planning care for a client who has septic shock. Which of the following is the
priority action for the nurse to take? - Administering antibiotic therapy
18. A nurse in the emergency department is caring for a client who has an allergic reaction
to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of
the following medications should the nurse expect to administer first? - seizure activity,
Respiratory rate 42/min, Weak, thready pulse.
19. A nurse in a cardiac unit is assisting with the admission of a client who is to undergo
hemodynamic monitoring. Which of the following actions should the nurse anticipate
performing? - Assist with insertion of pulmonary artery catheter
20. A nurse in the emergency department is assessing a client who was in a motor vehicle
crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood
pressure 118/68 mmHg, heart rate o 124/min, respiratory rate 38/min, temperature 38.6
C and Sa02 of 92% on room air. Which of the following actions should the nurse take
first? - Obtain a chest x-ray.
21. A client has the following arterial blood gas values: pH 7.52, Pa02 50 mmHg, PaC02 28
mmHg, HCO3 24 mEq/L. Based upon the client's Pa02, which of the following
conclusions would be accurate? - The client is severely hypoxic.
22. following organisms most commonly causes community-acquired pneumonia in adults -
Streptococcus pneumonia
23. A COPD patient's stimulus to breathe is- Hypoxemia
24. An elderly client has been ill with the flu, experiencing headache, fever and chills.
After 3 days, she developed a cough producing yellowish sputum. The nurse auscultates
her lungs and hears diffuse crackles. How would the nurse best interpret these
assessment findings? - It is likely that the client is developing a secondary bacterial
pneumonia.
25. A client with pulmonary embolism has pleuritic chest pain and hemoptysis. The nurse
would assess the presence of hemoptysis as an indication of - Alveolar damage
26. A patient with COPD reports steady weight loss and being "too tired from just breathing
to eat." Which of the following nursing diagnoses would be most appropriate when
planning nutritional interventions for this client? - Altered nutrition: less than body
requirements related to fatigue.
27. Which of the following diets would be most appropriate for a client with COPD? - High
calorie, high protein diet
28. Which of the following is the primary reason to teach pursed-lip breathing to clients with
emphysema? - To promote carbon dioxide elimination.
29. A client with COPD has severe shortness of breath at rest and arterial oxygen tension
(Pa02) of 35 mmHg. When oxygen via nasal cannula is prescribed, the nurse would
deliver the 02 at the flow rate of: - 2 L/min
30. A nurse working on a medical surgical unit admits a client. Two hours after admission,
the client's Sa02 is 91% and he is exhibiting wheezes and use of accessory muscles.
Which of the following medications should the nurse expect to administer? -
Beta2-agonist
31. A male patient's chest x-ray result reveals bilateral "white-outs," indicating acute
respiratory distress syndrome (ARDS). This syndrome results from: - Increased
pulmonary capillary permeability.
32. A nurse is planning care for a client who has acute respiratory distress syndrome
secondary to COVID-19. Which of the following should be included in the plan of care for
this client? Select all that apply. - Providing supplemental oxygen, Administration of
bronchodilators, Maintaining ventilatory support.
33. A nurse is assessing a client who has experienced a gunshot wound. Findings include
blood pressure of 108/55 mmHg, HR 124/min, RR 36/min, temp 36.80C, and Sa02 95%
on oxygen 15 L/min via non rebreather mask. The client reports dyspnea and pain. The
nurse reassessed the client 30 min later. Which of the following should the nurse report
to the physician? Select all that apply. - Distended neck veins, Tracheal deviation, Heart
rate 154/min
34. A nurse is reviewing the prescription for a client who has a pneumothorax. Which of the
following actions should the nurse perform first? - Prepare for chest tube insertion.
35. A nurse in the emergency department is assessing a client with a suspected flail chest.
Which of the following clinical findings confirm this diagnosis? Select all that apply.
- Cyanosis, Hypotension, Dyspnea, Paradoxic chest movement
36. A nurse is assessing a client who is in respiratory distress. The nurse should recognize
which of the following can cause a low pulse oximetry reading? - Nail polish Inadequate
peripheral perfusion, edema.
37. A nurse is caring for a client following a thoracentesis. Which of the following clinical
manifestations should the nurse recognize as risks for complications - Dyspnea, fever,
hypotension.
38. A nurse is preparing to care for a client following chest tube replacement. Which of the
following items should be available in the client's room? Select all that apply - Oxygen,
Sterile water, Enclosed hemostat clamps, occlusive dressing.
39. A nurse is assessing a client who has a chest tube and drainage system in place. Which
of the following are expected findings? - Gentle constant bubbling in the suction control
chamber, Gentle constant bubbling in the suction control chamber, Obtain a chest x-ray
40. Which of the following clients have an increased risk for developing pneumonia? - Client
who has dysphagia, client who has ARDS, Client who has a closed head injury and is
receiving mechanical ventilation, Client who has myasthenia gravis
41. A nurse is caring for a client who has pneumonia. Assessment findings include
temperature of 37.8 deg Celsius, respirations 30/min, BP 130/76, heart rate 100/min,
and Sa02 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority,
prioritize the following nursing interventions. - Administer oxygen therapy, Administer an
antipyretic medication to promote client comfort.
42. A nurse is instructing a client on the use of an incentive spirometer. Which of the
following statements made by the client indicates an understanding of the teaching? - "I
will take in a deep breath and hold it before exhaling."
43. A nurse is planning care for a client who has severe acute respiratory distress syndrome
(SARS). Which of the following should be included in the plan of care for this client? -
Providing supplemental oxygen, Administration of bronchodilators, Maintaining
ventilatory support.
44. A nurse is admitting a client who has. a suspected myocardial infarction (MI) and a
history of angina. Which of the following findings will help the nurse distinguish angina
from an MI? - Angina can be relieved with rest and nitroglycerin.
45. A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a
diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago.
Which of the following cardiac enzymes would confirm the infarction occurred 14 days
ago? - Troponin 1
46. A nurse is caring for a client in a clinic who asks why her physician prescribed 1 aspirin
per day. Which of the following is an appropriate response by the nurse?- "Aspirin
reduces the formation of blood clots that could cause a. heart attack."
47. A nurse is instructing a client who has angina about a new prescription for metoprolol
tartrate (Lopressor). Which of the following statements by the client indicates
understanding of the teaching? - "I will call my doctor if my pulse rate is less than 60."
48. A nurse is presenting a community education program on recommended lifestyle
changes to prevent angina and myocardial infarction. Which of the following changes
should the nurse recommend be made first? - smoking cessation
49. You are the student nurse on duty at the emergency department when a patient is
rushed in with DOB, clutching his chest and complaining of feeling cold. Prioritize your
interventions for an acute myocardial infarction.
- 1 6 mg morphine sulphate IV bolus
- 3 Start IV line with PNSS 1L x KVO
- 4 Start Isoket drip at 5 mg/hr
- 5 Administer Aspirin 325 mg and Clopidogrel
- 1300 mg P.O. Instruct the patient to chew before swallowing.
50. A nurse is caring for several clients. Which of the following clients are at risk for having a
pulmonary embolism? Select all that apply. - A client who has a BMI of 30, A client has a
fractured femur, A client has a fractured femur.
51. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis.
The client states that she is anxious because she feels that she cannot get enough air.
Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature 38.4 C, and
blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this
time? - Administer oxygen therapy.
52. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical
manifestations should the nurse expect to find? - Pleural friction rub, Petechiae,
tachycardia.
53. A nurse is completing the admission assessment of a client who has suspected
pulmonary edema. Which of the following are expected findings? - tachypnea, persistent
cough, orthopnea.
54. 55. A nurse is orienting a newly licensed nurse in the care of a client who is
receiving hemodynamic monitoring. Which of the following statements by the
newly licensed nurse indicates the teaching was effective? - "A chest x-ray is
needed to verify placement
55. A nurse S caring for a client following a coronary artery bypass graft (CABG).
Hemodynamic monitoring has been initiated. Which of the following actions by
the nurse facilitate correct monitoring readings? - Level transducer to
phlebostatic axis. Zero transducer to room air, Observe trends in readings
Compare readings to physical assessment
56. A nurse is caring for a client who is receiving hemodynamic monitoring and has
the following thermodynamic readings: PAS 34 mmHg, PAD 21 mmHg. PAWP 16
mmHg, and CVP 12 mmHg. For which of the following is the client at risk? -
Heart failure, Cor pulmonale, Pulmonary hypertension, Peripheral edema.
57. A nurse is teaching a client the importance of remaining still following
angiography. Which of the following is an appropriate statement by the nurse? -
Too much activity places you at risk for bleeding.
58. 59. A nurse is reviewing a new prescription to administer 0.9% sodium chloride at
50 ml/hr to a client who is receiving hemodynamic monitoring and has an
indwelling IV catheter in the left hand. Which of the following sites can be used
for administering this solution - Peripheral saline lock, Port on proximal (CVP)
lumen of pulmonary artery (PA) catheter
59. A nurse in a cardiac unit is caring for a group of clients. The nurse should
recognize which of the following clients as being at risk for the development of a
dysrhythmia? - A client who has metabolic alkalosis, A client who has COPD, A
client who underwent stent placement in a coronary artery.
60. a nurse on a cardiac unit is caring for a client who telemetry. The nurse
recognizes the client's heart rate is 46/min and notifies the provider. The nurse
 should anticipate that which of the following management strategies will be used
for this client? - defibrillation
61. A student nurse is observing a cardioversion procedure and hears the team
leader call out, 'Stand clear:' The student should recognize the purpose of this
action is to alert personnel that - they cannot be in contact with equipment
connected to the client
62. A nurse is admitting a client who has a complete heart block as demonstrated by
ECG. The client's pulse rate is 34/min, blood pressure is 83/48 mmHg, and he is
lethargic and unable to complete sentences. Which of the following actions
should the nurse perform first? - Cleanse the client's skin with soap and water
63. A nurse is completing discharge teaching with a client who has a permanent
pacemaker. Which of the following statements by the client indicates a need for
further teaching?" - will have to disconnect my automatic garage door opener."
64. A nurse is caring for a client following an angioplasty that was inserted through
the femoral artery. While turning the client, the nurse discovers blood underneath
the client's lower back. The nurse should suspect. - bleeding from the incisional
site