1. :Question -90
The clinic nurse is reviewing the assessment findings for a
client who has been taking spironolactone (Aldactone) for
treatment of hypertension. Which of the following, if noted
in the client ’s record, would indicate that the client is
?experiencing a side effect related to the medication
:Options
A potassium level of 3.2 mEq/L . 1
A potassium level of 5.8 mEq/L . 2
Client complaint of constipation . 3
Client complaint of dry skin . 4
:Answer
. 2
:Rationale
Spironolactone is a potassium-sparing diuretic. Side effects
include hyperkalemia, dehydration, hyponatremia, and
lethargy. Although the concern with most diuretics is
hypokalemia, this medication is potassium sparing, which
means that the concern with this medication is
hyperkalemia. Additional side effects include nausea,
vomiting, cramping, diarrhea, headache, ataxia,
.drowsiness, confusion, and fever
:Question -91
A nurse is providing instructions to the client with chronic
atrial fibrillation who is being started on quinidine sulfate.
:The nurse plans to instruct the client to

2. :Options
.Take the medication only on an empty stomach . 1
Open the sustained-release capsules and mix with . 2
applesauce if the medication is difficult to swallow. 3 .
.Wear a medical identification bracelet
Stop taking the prescribed digoxin (Lanoxin) when . 4
.this medication is started
:Answer
. 3
:Rationale
The client should be instructed to take quinidine sulfate
exactly as prescribed. The client should not chew the
sustained-release capsules or open the capsules and mix
them with food. The client should be instructed to wear a
medical identification bracelet or tag and to continue
taking digoxin as prescribed. Quinidine sulfate is
administered for atrial flutter or fibrillation only after the
client has been digitalized
.
:Question -92
A nurse is reviewing the electrocardiogram (ECG) rhythm
strip obtained on a client with a diagnosis of myocardial
infarction . The nurse notes that the PR interval is 0.20
:second . The nurse determines that this is
:Options
A normal finding . 1
Indicative of atrial flutter . 2

3. Indicative of impending reinfarction . 3
Indicative of atrial fibrillation . 4
:Answer
. 1
:Rationale
The PR interval represents the time it takes for the cardiac
impulse to spread from the atria to the ventricles . The
normal range for the PR interval is 0.12 to 0.20 second .
Options 2 , 3 , and 4 are incorrect
:Question -93
A nurse is documenting information in a client ’s chart
when the ECG telemetry alarm sounds and the nurse notes
that the client is in ventricular tachycardia (VT). The
nurse rushes to the client ’s bedside and performs which
?assessment first
:Options
Blood pressure . 1
Cardiac rate . 2
Respiratory rate . 3
Responsiveness of the client . 4
:Answer
. 4
:Rationale
VT is associated with a significant decrease in cardiac
output. Assessing for unresponsiveness determines whether
the client is affected by the decreased cardiac output .
Although options 1 , 2 , and 3 may be a component of the

4. assessment, the first action would be to determine
responsiveness of the client
.
:Question -94
A nurse in the medical unit is assigned to provide
discharge teaching to a client with a diagnosis of angina
pectoris. The nurse is discussing lifestyle changes that are
needed to minimize the effects of the disease process. The
client continuously changes the subject during the teaching
session. The nurse interprets that this client ’s behavior is
:most likely to indicate
:Options
An attempt to ignore or deny the need to make . 1
lifestyle changes
Boredom resulting from having already learned the . 2
material
Anxiety related to the need to make lifestyle changes . 3
Lack of understanding of the material provided at the . 4
teaching session and embarrassment about asking
questions
:Answer
. 1
:Rationale
Denial is a defense mechanism that allows the client to
minimize a threat that may be manifested by refusal to
discuss what has happened. Denial is a common early
reaction associated with chest discomfort, angina, or

5. myocardial infarction (MI). Anxiety usually is manifested
by symptoms of sympathetic nervous system arousal. No
data are provided in the question that would lead the
nurse to interpret the client ’s behavior as boredom or as
either understanding or not understanding the material
.provided at the teaching session
:Question -95
A nurse is reviewing the laboratory results for a client who
arrives at the health care clinic for follow-up assessment
after insertion of a mechanical prosthetic heart valve. The
international normalized ratio (INR) is analyzed because
the client has been taking warfarin sodium (Coumadin)
since discharge from the hospital. The nurse determines
that the INR range is appropriate if which of the following
?values is noted on the laboratory report
:Options
2.0 . 1
2.3 . 2
3.0 . 3
5.0 . 4
:Answer
. 3
:Rationale
The recommended INR range for oral anticoagulant
therapy is 2.0 to 3.0 , but this value may vary with the
goals of therapy . A recommended INR range with
mechanical prosthetic heart valve is 2.5 to 3.5 , and for

6. survivors of acute myocardial infarction (MI ) , 2.5 to 3.5
.
:Question -96
A clinic nurse is performing a cardiovascular assessment
on a client. In preparing to assess the client ’s apical pulse,
the nurse places the stethoscope over the heart ’s apex in
?which of the following positions
:Options
At the midline of the chest just below the xiphoid . 1
process
At the midclavicular line at the fifth left intercostal . 2
space
At the midaxillary line on the left side of the chest . 3
Mid-sternum, equal with the nipple line . 4
:Answer
. 2
:Rationale
The heart is located in the mediastinum. Its apex or distal
end points to the left and lies at the level of the fifth
intercostal space. A stethoscope should be placed in this
area to pick up heart sounds most clearly. The other
options are incorrect because they do not represent the
.anatomical positioning of the heart ’s apex
:Question -97
A nurse is caring for a client who has been hospitalized
with a diagnosis of angina pectoris. The client is receiving

7. oxygen via nasal cannula at 2 L/min . The client asks why
the oxygen is necessary . The nurse accurately explains
:that
:Options
.Oxygen has a calming effect . 1
Oxygen will prevent the development of any . 2
.thrombus
Oxygen dilates the blood vessels so they can supply . 3
more nutrients to the heart muscle. 4 . The pain of angina
pectoris occurs because of decreased oxygen supply to the
.heart
:Answer
. 4
:Rationale
The pain associated with angina results from ischemia of
myocardial cells. The pain often is precipitated by activity
that places more oxygen demand on heart muscle.
Supplemental oxygen will help to meet the added demands
on the heart muscle. Oxygen does not dilate blood vessels
or prevent thrombus formation and does not directly calm
.the client
:Question -98
A nurse is assisting in performing an arterial blood gas
analysis on a client. Which of the following is an
appropriate nursing action after the blood specimen is
?drawn
:Options

8. . Cover the site with a 4 × 4 gauze . 1
.Apply warm packs to the site . 2
Perform passive range of motion for the fingers of the . 3
.hand
.Apply pressure to the site . 4
:Answer
. 4
:Rationale
Pressure should be applied to the site after an arterial
blood gas specimen is drawn. The blood pressure in the
artery is higher than in the veins, so applying pressure to
the punctured artery is necessary to control bleeding.
Covering the site with gauze may protect the site but
would not control bleeding. Heat (by application of warm
packs) causes vasodilation, which would increase bleeding
.to the site. Exercise would increase circulation to the area
:Question -99
A client is admitted to the critical care unit with a
diagnosis of suspected myocardial infarction. The unit
nurse is reviewing the laboratory test results for this client.
Which of the following findings would most specifically
?(indicate the presence of a myocardial infarction (MI
:Options
Increased CK-MB . 1
Increased CK-MM . 2
(Increased blood urea nitrogen (BUN . 3

9. Decreased white blood cell (WBC) count . 4
:Answer
. 1
:Rationale
The MM fraction of creatine kinase (CK-MB) is specific
in determining the presence of MI. The CK-MM reflects
injury to skeletal muscle. The WBC count would most
likely be elevated in the client with an MI. The BUN is
.unrelated to this disorder
:Question -100
A nurse is caring for a client with a diagnosis of
myocardial infarction (MI). The client is experiencing
chest pain that is unrelieved by the administration of
nitroglycerin. The nurse administers morphine sulfate to
the client as prescribed by the physician. After
administration of the morphine sulfate, the nurse plans to
:monitor
:Options
Mental status . 1
Respirations and blood pressure . 2
Urinary output . 3
Temperature and blood pressure . 4
:Answer
. 2
:Rationale
Morphine sulfate is an opioid analgesic that may be
administered to relieve pain in a client with MI. Although

10. monitoring mental status is a component of the nurse ’s
assessment, it is not the priority after administration of
morphine sulfate. The nurse would monitor the client ’s
respirations and blood pressure. Signs of morphine toxicity
include respiratory depression and hypotension. Urinary
output is unrelated to the administration of this
medication. Monitoring the temperature also is not
.associated with the use of this medication
:Question -101
A client hospitalized with a diagnosis of myocardial
infarction calls for the unit nurse because she is
experiencing chest pain. The nurse administers a
sublingual nitroglycerin tablet as prescribed. The client,
who is receiving oxygen by nasal cannula, reports that her
chest pain is unrelieved by the nitroglycerin. Which of the
following is the next appropriate nursing action for this
?client
:Options
.Administer another nitroglycerin tablet . 1
.Increase the flow rate of oxygen . 2
.Contact the physician . 3
.Call the client ’s family . 4
:Answer
. 1
:Rationale
Nitroglycerin tablets are administered one tablet every 5
minutes , for a total of three tablets per episode of chest

11. pain , so long as the client maintains a systolic blood
pressure of 100 mm Hg or higher. Increasing the flow rate
of oxygen may be prescribed by the physician but would
not be the next nursing action. If three nitroglycerin
tablets did not relieve the client ’s chest pain, the physician
needs to be notified. It is premature to call the client ’s
.family
:Question -102
A client with a diagnosis of angina pectoris is hospitalized
for an angioplasty. The client returns to the nursing unit
after the procedure, and the nurse provides instructions to
the client regarding home care measures. Which of the
following statements if made by the client indicates an
?understanding of the instructions
:Options
I am so relieved that I can eat anything that I want” . 1
“ .to now
“ .I need to cut down on cigarette smoking” . 2
“ .I am so relieved that my heart is repaired” . 3
“ .I need to adhere to my dietary restrictions” . 4
:Answer
. 4
:Rationale
After angioplasty, the client needs to be instructed
regarding the specific dietary restrictions that must be
followed. Making the recommended dietary and lifestyle
changes will assist in preventing further atherosclerosis.

12. 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. Level of
:Question -103
A nurse is caring for a client with a diagnosis of
myocardial infarction (MI) and is assisting the client in
completing the diet menu. Which of the following
beverages would the nurse instruct the client to select from
?the menu
:Options
Coffee . 1
Tea . 2
Lemonade . 3
Cola . 4
:Answer
. 3
:Rationale
A client with a diagnosis of MI should not consume
caffeinated beverages. Caffeinated products can produce a
vasoconstrictive effect, leading to further cardiac ischemia.
Coffee, tea, and cola all contain caffeine and need to be
.avoided in the client with MI
:Question -104
A nurse is performing an admission assessment on a client
with a diagnosis of angina pectoris who takes nitroglycerin
for chest pain at home. During the assessment, the client

13. complains of chest pain. The nurse immediately asks the
?client which of the following questions
:Options
“ ?Are you having any nausea” . 1
“ ?Where is the pain located” . 2
“ ?Are you allergic to any medications” . 3
“ ?Do you have your nitroglycerin with you” . 4
:Answer
. 2
:Rationale
If a client complains of chest pain, the initial assessment
question would be to ask the client about the pain intensity
, location , duration , and quality . Although options 1 , 3 ,
and 4 all may be components of the assessment, none of
these questions would be the initial assessment question in
.this client
:Question -105
A nurse has provided dietary instructions to a client with
coronary artery disease. Which statement by the client
?indicates an understanding of the dietary instructions
:Options
.I need to substitute eggs and whole milk for meat” . 1
“
I should eliminate all cholesterol and fat from my” . 2
“ .diet
“ .I should use polyunsaturated oils in my diet” . 3
“ .I ’ll need to become a strict vegetarian” . 4

14. :Answer
. 3
:Rationale
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