Cardiovascular Practice Questions Answers and Rationales

Level 1

1) Correct answer: C
a. The sodium level can increase with the use of several types of products, including
toothpaste and mouthwash; over-the-counter medications such as analgesics,
antacids, laxatives, and sedatives; and softened water and mineral water. Clients
are instructed to read labels for sodium content. Water that is bottled, distilled,
deionized, or demineralized may be used for drinking and cooking. Fresh fruits
and vegetables are low in sodium.
2) Correct answer: C
a. Cardiac troponin T or cardiac troponin I have been found to be a protein marker
in the detection of myocardial infarction, and assay for this protein is used in
some institutions to aid in the diagnosis of a myocardial infarction. The test is not
used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation.
3) Correct answer: A
a. The client with heart failure may present with different symptoms, depending on
whether the right or the left side of the heart is failing. Peripheral and sacral
edema, jugular vein distention, and organomegaly all are manifestations of
problems with right-sided heart function. Lung sounds constitute an accurate
indicator of left-sided heart function.
4) Correct answer: B
a. The client with coronary artery disease should avoid foods high in saturated fat
and cholesterol such as eggs, whole milk, and red meat. These foods contribute to
increases in low-density lipoproteins. The use of polyunsaturated oils is
recommended to control hypercholesterolemia. It is not necessary to eliminate all
cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
5) Correct answer: C
a. The client should wear loose, comfortable clothing for the procedure.
Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt
that buttons in the front. The client should receive nothing by mouth after bedtime
or for a minimum of 2 hours before the test. The client should wear rubber-soled,
supportive shoes, such as athletic training shoes. The client should avoid smoking,
alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation
can interfere with the test, with the potential for a false-positive result.
6) Correct answer: C
a. Triamterene is a potassium-retaining diuretic, so the client should avoid foods
high in potassium. Fruits that are naturally higher in potassium include avocados,
bananas, fresh oranges, mangos, nectarines, papayas, and prunes.
7) Correct answer: B
a. Spironolactone is a potassium-retaining diuretic, and the client should avoid foods
high in potassium. If the client does not avoid foods high in potassium,
hyperkalemia could develop. The client does not need to avoid foods that contain
calcium, magnesium, or phosphorus while taking this medication.
8) Correct answer: C
 a. The client with heart failure may present with different symptoms, depending on
whether the right side or the left side of the heart is failing. Adventitious breath
sounds, such as crackles, are an indicator of decreased left-sided heart function.
Peripheral edema, jugular vein distention, and ascites all can be present because
of insufficiency of the pumping action of the right side of the heart.
9) Correct answer: B
a. Thrombolytic drugs are administered within 6 hours after onset of an MI to lyse
clots and reduce the extent of myocardial damage.
10) Correct answer: A
a. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation
makes it easier for the heart to eject blood, resulting in decreased oxygen needs.
Decreased oxygen demand reduces pain caused by heart muscle not receiving
sufficient oxygen. While blood pressure may decrease due to the vasodilation
effects of nitroglycerin, it is only secondary and not related to the angina the
client is experiencing. Increased blood pressure would mean the heart would
work harder, increasing oxygen demand and thus angina. Decreased heart rate is
not an effect of nitroglycerin.
11) Correct answer: D
a. The thrombolytic, agent t-PA, administered intravenously, lyses the clot blocking
the coronary artery. The drug is most effective when administered within 6 hours
after onset of MI. The drug does not reduce coronary artery vasospasm.; nitrates
are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic
drugs. Surgical approaches are used to open the coronary artery and re-establish a
blood supply to the area.
12) Correct answer: A
a. Cardiac arrhythmias are commonly observed with administration of t-PA.
Cardiac arrhythmias are associated with reperfusion of the cardiac tissue.
Hypotension is commonly observed with administration of t-PA. Seizures and
hypothermia are not generally associated with reperfusion of the cardiac tissue.
13) Correct answer: B
a. A history of cerebral hemorrhage is a contraindication to administration of t-PA
because the risk of hemorrhage may be further increased. Age >60 years, history
of heart failure, and cigarette smoking are not contraindications.
14) Correct answer: C
a. Pasta, tomato sauce, salad, and coffee would be the best selection for this client
following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods
tend to be high in cholesterol.
15) Correct answer: B
a. Cardiac catherization is done in clients with angina primarily to assess the extent
and the severity of the coronary artery blockage. A decision about medical
management, angioplasty, or coronary artery bypass surgery will be based on the
catherization results. Coronary bypass surgery would be used to bypass
obstructed vessels. Although cardiac catheterization can be used to assess the
functional adequacy of valves and heart muscle, in this case the client has
unstable angina and therefore would need the procedure to assess the extent of
arterial blockage.
16) Correct answer: B
a. Late onset of puberty is not generally considered to be a risk factor for
development of atherosclerosis. Risk factors for atherosclerosis include family
history, cigarette smoking, hypertension, high blood cholesterol level, male
gender, diabetes mellitus, obesity, and physical inactivity.
17) Correct answer: C
a. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen
consumption and demand. Vasodilation in coronary arteries and collateral vessels
may also increase blood flow to the ischemic areas of the heart. Nitroglycerin
decreases myocardial oxygen demand. Nitroglycerin does not have an effect on
pericardial spasticity or conductivity in the myocardium.
18) Correct answer: C
a. Warfarin is an anticoagulant, which is used in the treatment is atrial fibrillation
and decreased left ventricular ejection fraction (<20%) to prevent thrombus
formation and release of emboli into the circulation. The client may also take
other medication as needed to manage the heart failure. Warfarin does not reduce
circulatory load or improve myocardial workload. Warfarin does not affect
cardiac rhythm.
19) Correct answer: C
a. Sitting almost upright in bed with the feet and legs resting on the mattress
decreases venous return to the heart, thus reducing myocardial workload. Also,
the sitting position allows maximum space for lung expansion. Low Fowler’s
position would be used if the client could not tolerate high Fowler’s position for
some reason. Lying on the right side would not be a good position for the client
in heart failure. The client in heart failure would not tolerate Trendelenburg’s
position.
20) Correct answer: B
a. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic
activity causes increased strength of myocardial contractions and thereby
increases output of blood from the left ventricle. Digoxin does not dilate coronary
arteries. Although digoxin can be used to treat arrhythmias and odes decrease the
electrical conductivity of the myocardium, these are not primary reasons for its
use in clients with heart failure and pulmonary edema.
21) Correct answer: A
a. After intravenous administration of furosemide, diuresis normally begins in about
5 minutes and reaches it peak within about 30 minutes. Medication effects last 2
to 4 hours. When furosemide is given intramuscularly or orally, drug action
begins more slowly, and lasts longer than when given intravenously.
22) Correct answer: D
a. When diuretics are given early in the day, the client will void frequently during
the daytime hours and will not need to void frequently during the night.
Therefore, the client’s sleep will not be disturbed. Taking furosemide in the
morning has no effect on preventing electrolyte imbalances or retarding rapid
drug absorption. The client should not accumulate excessive fluids throughout
the night.
23) Correct answer: C
 a. Colored vision and seeing yellow spots are symptoms of digoxin toxicity.
Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of
digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial
fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure
are not associated with digoxin toxicity.
24) Correct answer: D
a. A low serum potassium level (hypokalemia) predisposes a client to digoxin
toxicity. Because potassium inhibits cardiac excitability, a low serum potassium
level would mean that the client would be prone to increased cardiac excitability.
Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin
toxicity.
25) Correct answer: B
a. Canned foods or juices such as tomato juice are typically high in sodium and
should be avoided in a sodium-restricted diet. Canned foods and juices in which
sodium has been removed or limited are available. The client should be taught to
read labels carefully. Apples and whole wheat breads are not high in sodium.
Beef tenderloin would have less sodium than canned foods or tomato juice.
26) Correct answers: B, C, D
a. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges
are examples of foods high in potassium. Angel food cake and peppers are low in
potassium.
27) Correct answer: C
a. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR
is the prothrombin time ratio that would be obtained if the thromboplastin reagent
from the World Health Organization was used for the plasma test. It is now the
recommended method to monitor effectiveness of warfarin sodium. Generally,
the INR for clients administered warfarin sodium should range from 2 to 3. In the
past, prothrombin time was used to assess effectiveness of warfarin sodium and
was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time
is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or
vitamin K is used to reverse warfarin sodium anticoagulant effect, whereas
protamine sulfate reverses the effects of heparin. Warfarin sodium will help to
prevent blood clots.
28) Correct answer: A
a. The effect of a beta-blocker is a decrease in heart rate, contractility, and afterload,
which leads to a decreased in blood pressure. The client at first may have an
increase in fatigue when starting the beta-blocker. The mechanism of action does
not improve blood sugar or urine output.
29) Correct answers: A, C, E
a. Clonidine is a central-acting adrenergic antagonist. It reduces sympathetic output
from the central nervous system. Dry mouth, impotence, and sleep disturbances
are possible side effects. Hyperkalemia and pancreatitis are not anticipated with
use of this drug.
30) Correct answer: A
a. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol including
reducing heart rate, decreasing myocardial contractility, and slowing conduction.
 Propranolol does not increase norepinephrine secretion, cause vasodilation, or
block conversion of angiotensin I to angiotensin II.

Level 2

1) Correct answer: C
a. After angioplasty, the client needs to be instructed on the specific dietary
restrictions that must be followed. Making the recommended dietary and lifestyle
changes will assist in preventing further atherosclerosis. Abrupt closure of the
artery can occur if the dietary and lifestyle recommendations are not followed.
Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.
2) Correct answer: C
a. The pain of MI is not relieved by rest and nitroglycerin and requires opioid
analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to
the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is
accompanied by few associated symptoms, and is relieved by rest and
nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and
neck. It typically begins spontaneously, lasts longer than 30 minutes, and
frequently is accompanied by associated symptoms (such as nausea, vomiting,
dyspnea, diaphoresis, or anxiety).
3) Correct answer: C
a. Chest pain is assessed by using the standard pain assessment parameters (e.g.,
characteristics, location, intensity, duration, precipitating and alleviating factors,
and associated symptoms). The remaining options may or may not help
discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens
on inspiration.
4) Correct answer: A
a. Obesity and sodium intake are modifiable risk factors for hypertension. These are
of the utmost importance because they can be changed or modified by the
individual through a regular exercise program and careful monitoring of sodium
intake. Protein intake has no relationship to hypertension.
5) Correct answer: B
a. To best monitor that the client’s circulation remains intact, the dorsal surface of
the right foot should be palpated. When the left side of the heart is catheterized,
the cannula enters via an artery. In this instance, the right femoral artery was
accessed. While all options assess arterial points of the right leg, the dorsal
surface of the right foot (the pedal pulse) is the most distal. If this pulse point is
present and unchanged from before the procedure, the other pulse points should
also be intact.
6) Correct answer: A
a. The client is having symptoms of a myocardial infarction. The first action is to
prevent platelet formation and block prostaglandin synthesis. The client should
place the tablet under the tongue and wait until it is absorbed. Nitroglycerin
tablets are not effective if chewed, swallowed, or placed between the cheek and
gums.
7) Correct answers: A, C, D
a. Clopidogrel is generall well-absorbed and may be taken with or without food; it
should be taken at the same time every day, and, while food may help prevent
potential GI upset, food has no effect on absorption of the drug. Bleeding is the
most common adverse effect of clopidogrel; the client must understand the
importance of reporting any unexpected, prolonged, or excessive bleeding
including blood in urine or stool. Increased bruising and bleeding gums are
possible side effects of clopidogrel; the client should be aware of this possibility.
Plavix is an anti-platelet agent used to prevent clot formation in clients that have
experienced or are at risk for myocardial infarction, ischemic stroke, peripheral
artery disease, or acute coronary syndrome. It is not necessary to drink a glass of
water after taking clopidogrel.
8) Correct answer: C
a. Nitroglycerin can be taken prophylactically before stressful physical activities
such as stair climbing to help the client remain pain free. Climbing the stairs
early in the day would have no impact on decreasing pain episodes. Resting
before or after an activity is not as likely to help prevent an activity-related pain
episode.
9) Correct answer: C
a. The client taking nifedipine should inspect the gums daily to monitor for gingival
hyperplasia. This is an uncommon adverse effect but one that required
monitoring and intervention if it occurs. The client taking nifedipine might be
taught to monitor blood pressure, but more often than monthly. These clients
would not generally need to perform daily weights or limit intake of green leafy
vegetables.
10) Correct answers: B, E, F
a. Simvastatin is used in combination with diet and exercise to decrease elevated
total cholesterol. The client should take simvastatin in the evening, and the nurse
should instruct the client that if a dose is missed, to take it as soon as remembered,
but not to take at the same time as the next scheduled dose. It is not necessary to
take the pill with food. The client does not need to limit greens (limiting greens is
appropriate for client taking warfarin), but the nurse should instruct the client to
avoid grapefruit and grapefruit juice, which can increase the amount of drug in the
bloodstream. A serious side effect is myopathy, and the client should report
muscle pain or tenderness to the HCP.
11) Correct answer: B
a. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting.
Visual disturbances can also occur including double or blurred vision and visual
halos. Hypokalemia is a common cause of digoxin toxicity associated with
arrhythmias because low serum potassium can enhance ectopic pacemaker
activity. Although vomiting can lead to fluid deficit given the patient’s history,
the vomiting is more likely due to the adverse effects of digoxin toxicity.
Pulmonary edema is manifested by dyspnea and coughing.
12) Correct answers: D, E
 a. Signs of pulmonary edema are identical to those of acute heart failure. Signs and
symptoms are generally apparent in the respiratory system and include coarse
crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to
sympathetic stimulation in the presence of hypoxemia. Blood pressure may
decrease or be elevated, depending on the severity of the edema. Jugular vein
distention, dependent edema, and anorexia are symptoms of right-sided heart
failure.
13) Correct answers: A, B, C, E
a. Heart failure can be a result of several cardiovascular conditions, which will
affect the heart’s ability to pump effectively. The body attempts to compensate
through several neurohormonal mechanisms. Decreased cardiac output stimulates
the aortic and carotid baroreceptors, which activates the sympathetic nervous
system to release norepinephrine and epinephrine. This early response increases
the heart rate and contractility. It also has some negative effects, including
vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion
(due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone
process resulting in the release of anti-diuretic hormone. This causes fluid
retention in an attempt to increase blood pressure, and therefore, cardiac output.
In the damaged heart, this causes fluid overload. There is no parasympathetic
response. Decreased pulmonary perfusion can be a result of fluid overload or
concomitant pulmonary disease.
14) Correct answer: A
a. Increasing cardiac output is the main goal of therapy for the client with heart
failure or pulmonary edema. Pulmonary edema is an acute medical emergency
requiring immediate intervention. Respiratory status and comfort will be
improved when cardiac output increases to an acceptable level. Peripheral edema
is not typically associated with pulmonary edema.
15) Correct answer: C
a. Heart failure is a complex and chronic condition. Education should focus on
health promotion and preventative care in the home environment. Signs and
symptoms can be monitored by the client. Instructing the client to obtain daily
weights at the same time each day is very important. The client should be told to
call their HCP if there has been a weight gain of 2 lbs or more. This may indicate
fluid overload, and treatment can be prescribed early, on an outpatient basis,
rather than waiting until the symptoms become life-threatening. Following a
high-fiber diet is beneficial, but is not relevant to the teaching needs of a client
with heart failure. Prescribing an exercise program for the client such as walking
2 miles every day, would not be appropriate at discharge. The client exercise
program would need to be planned in consultation with the HCP and based on the
history and physical condition of the client. The client may require exercise
tolerance testing before an exercise plan is laid out. Although the nurse does not
prescribe an exercise program for the client, a sedentary lifestyle should not be
recommended.
16) Correct answers, A, B, D
a. If the client will call the healthcare provider (HCP) when there is increasing
shortness of breath, weight gain over 2 lbs in one day, and the need to sleep sitting
 up, this indicates an understanding of teaching because these signs and symptoms
suggest worsening of client’s heart failure. Although the client will most likely be
placed on a sodium restricted diet, the client would not need to notify the HCP if
he or she consumed a high-sodium breakfast. Instead the client would need to be
alert for possible signs and symptoms of worsening heart failure and work to
reduce sodium intake for the rest of that day and in the future.
17) Correct answer: B
a. There was a significant change in both blood pressure and heart rate with position
change. This indicates inadequate blood volume to sustain normal values.
Normal postural changes allow for an increase in heart rate of 5 to 20 bpm, a
possible slight decrease of <5 mm Hg in the systolic BP and a possible slight
increase of <5 mm in the diastolic BP.
18) Correct answer: A
a. Furosemide is a diuretic often prescribed for clients with hypertension or heart
failure; the drug should not affect a client’s ability to drive safely. Furosemide
may cause orthostatic hypotension, and clients should be instructed to be careful
when changing from supine to sitting to standing position. Diuretics should be
taken in the morning if possible to prevent sleep disturbances due to the need to
get up to void. Furosemide is a loop diuretic that is not potassium sparing; clients
should take potassium supplements as prescribed and have their serum potassium
levels checked at prescribed intervals.
19) Correct answer: B, C
a. Changing positions slowly and avoiding long periods of standing may limit the
occurrence of orthostatic hypotension. Scheduling regular medication times is
important for blood pressure management, but this aspect is not related to the
development of orthostatic hypotension. Excessive alcohol intake and hot baths
are associated with vasodilation.
20) Correct answer: A
a. Atenolol is a beta-adrenergic antagonist indicated for management of
hypertension. Sudden discontinuation of this drug is dangerous because it may
exacerbate symptoms. The medication should not be discontinued without a
prescription. Blood pressure needs to be monitored more frequently than annually
in a client that is newly diagnosed and treated for hypertension. Clients are not
usually placed on a low protein diet for hypertension.
21) Correct answer: C
a. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all
high in both fat and sodium and should be avoided on a low-calorie, low-fat, low
salt diet. Dietary restrictions of all types are complex and difficult to implement
with clients who are basically symptomatic.
22) Correct answers: A, B, D, F
a. Metoprolol is a beta-adrenergic blocker indicated for hypertension, angina, and
myocardial infarction. The tablets should be taken with food at the same time
each day; they should not be chewed or crushed. The HCP should be notified if
the pulse falls below 50 for several days. Blood glucose should be checked
regularly during therapy since increased episodes of hypoglycemia may occur. It
may mask evidence of hypoglycemia such as palpitations, tachycardia, and
 tremor. Use of any OTC decongestants, asthma, and cold remedies, and herbal
preparations must be avoided. Fainting spells may occur due to exercise or stress,
and the dosage of the drug may need to be reduced or discontinued.
23) Correct answers: A, B, C, E
a. Chlorothiazide causes increased urination and decreased swelling (if there is
edema) and weight loss. It is important to check and record weight two to three
times per week at same time of day with similar amounts of clothing. Clients
should not drink alcoholic beverages or take other medications without the
approval of the healthcare provider. Reducing sodium intake in the diet helps
diuretic drugs to be effective and allows smaller doses to be taken. Smaller doses
are less likely to cause adverse effects, and therefore, excessive table salt as well
as salty foods should be avoided. Chlorothiazide is a diuretic that is prescribed
for lower blood pressure and may cause dizziness and faintness when the client
stands up suddenly. This can be prevented or decrease by changing positions
slowly. If dizziness is severe, the HCP must be notified. Diuretics may cause
sensitivity to sunlight; hence the need to avoid prolonged exposure to sunlight,
use sunscreens, and wear protective clothing. Chlorothiazide causes increased
urination and must be taken early in the day to decrease nighttime trips to the
bathroom. Fewer bathroom trips means less interference with sleep and less risk
of falls. The client should not change the dosage without consulting the HCP.
24) Correct answer: C
a. (A) The therapeutic range for INR is 2 to 3; therefore, this client would not need
to be contacted first. (B) The client’s serum potassium level is within the normal
range—3.5 to 5.5 mEq/L. Therefore, this client would not need to be contacted
first. (C) The client’s digoxin level is higher than the therapeutic level for digoxin,
which is 0.8 to 2 mg/dL. This client should be contacted first to assess for signs/
symptoms of digoxin toxicity. (D) The glycosylated hemoglobin, which is the
average of blood glucose levels over 3 months, should not be more than 8%. This
client, with a level of 6%, does not need to be contacted.
25) Correct answers: A, B, D, E
a. (A) A 2-lb weight gain indicates the client is retaining fluid and should contact the
HCP. This is an appropriate teaching intervention. (B) Keeping the head of the
bed elevated will help the client breathe easier; therefore, this is an appropriate
teaching intervention. (C) The loop diuretic should be taken in the morning to
prevent nocturia. This is not an appropriate teaching intervention. (D) Sodium
retains water. Telling the client to avoid eating foods high in sodium is an
appropriate teaching intervention. (E) Isotonic exercise, such as walking or
swimming, helps tone the muscles, and discussing this with the client is an
appropriate teaching intervention.

Level 3

1) Correct answer: C
a. The normal heart rate is 60 to 100 beats/minute in an adult. If the nurse notes a
heart rate that is less than 60 beats/minute, the nurse would not administer the
digoxin and would further evaluate the client for signs and symptoms of digoxin
 toxicity. When clients are bradycardic, they may have symptoms of decreased
cardiac output, so this would also be assessed.
2) Correct answer: A
a. Further assessment is needed in this situation. It is premature to initiate other
actions until further data has been gathered. Inquiring about the onset, duration,
location, severity, and precipitating factors of the chest heaviness will provide
pertinent information to convey to the HCP.
3) Correct answer: C
a. The nurse should withhold the dose of captopril; captopril is an ACE inhibitor,
and a side effect of the medication is hyperkalemia. The BUN and creatinine,
which are normal, should be viewed prior to administration since renal
insufficiency is another potential side effect of an ACE inhibitor. The heart rate is
within normal limits. The nurse should question the dose of metoprolol if the
client’s heart rate is bradycardic. The hemoglobin and hematocrit are normal for
a female. The nurse should report the high potassium level and that the captopril
was withheld.
4) Correct answer: A
a. The ankle edema suggests fluid volume overload. The nurse should assess
respiratory rate, lung sounds, and SPO2 to identify any signs of respiratory
symptoms of heart failure requiring immediate attention. The nurse can then
draw blood for laboratory studies, insert the foley catheter, and weight the client.
5) Correct sequence: B, D, C, A
a. Even though the chest pain experience by Client 2 is resolved, it was recent and
requires reassessment. Client 4 is scheduled to leave for major surgery very soon.
The nurse should check this client and the client’s chart and make certain that
everything is ready so as to not delay the surgery. Client 3 has schedule
medications for blood pressure control. While not experiencing any acute
problem, this medication should be administered as scheduled. Client 1 is stable
at this time and can be seen last.
6) Correct answer: B
a. The client has gained 5 lb in 3 days with a steady increase in blood pressure. The
client is exhibiting signs of heart failure, and if the client is short of breath, this
will be another sign. Asking how the client is feeling is too general, and a more
focused question will quickly determine the client’s current health status. The
scales should be calibrated periodically, but a 5-lb weight gain, along with
increased blood pressure, is not likely due to problems with the scale. The weight
gain is likely due to fluid retention, not drinking too much fluid.
7) Correct answer: C
a. (A) The cardiac glycoside, such as digoxin, should not be administered unless the
apical pulse is 60 or above. (B) Because the client’s serum K+ level is already
low, the nurse should question administering a loop diuretic. (C) The client in
ventricular fibrillation is in a life-threatening situation; therefore, the
antidysrhythmic, such as lidocaine or amiodarone, should be administered first.
(D) The client’s blood pressure is above 90/60, so the calcium-channel blocker
can be administered but it is not priority over a client who is in a life-threatening
situation.
8) Correct answer: D
a. (A) The nurse would expect the client with a deep vein thrombosis to have an
edematous right calf, so the nurse would not need to assess this client first. (B)
The nurse would expect the client with mitral valve stenosis to have heart
palpitations (sensations of rapid, fluttering heartbeat). (C) The nurse would expect
the client with arterial occlusive disease to have intermittent claudication (leg
pain), so the nurse would not need to assess this client first. (D) The client would
not expect the client with congestive heart failure to have pink, frothy sputum
because this is a sign of pulmonary edema. This client should be assessed first.
9) Correct answer: C
a. (A) This client is at high risk for complications related to necrotic myocardial
tissue and will need extensive teaching; therefore, this client should not be
assigned to a new graduate. (B) Unstable angina means this client is at risk for
life-threatening complications and should not be assigned to a new graduate. (C)
A new graduate should be able to complete a pre-procedural checklist and get this
client to the catheterization lab. (D) Chest pain means this client could be having
a myocardial infarction and should not be assigned to a new graduate.
10) Correct answer: B
a. (A) The INR is not at a therapeutic level yet; the nurse should administer this
medication. (B) This potassium level is very low. Hypokalemia potentiates
dysrhythmias in clients receiving digoxin. This nurse should discuss potassium
replacement with the HCP before administering this medication. (C) An aspartate
aminotransferase (AST) test measures the amount of this enzyme in the blood.
The enzyme is part of the liver function panel. The normal is 14–20 U/L for males
and 10–36 U/L for females. (D) Creatinine level is reflective of renal status.
Normal is 0.6–1.2 mg d/L.
11) Correct answer: C
a. (A) Lasix should be administered to the client who has an adequate urinary
output. (B) Lovenox is prescribed to prevent deep vein thromboses (DVT) in
clients who are immobile, such as a postsurgical client. (C) The nurse should not
administer an antiplatelet medication to a client going to surgery because this will
increase postoperative bleeding. The nurse should hold this medication and
discuss this with the surgeon. (D) The client’s blood pressure is within an
acceptable range. The nurse should administer this medication.