1.

The nurse has admitted a client to the ER with complaints of

chest pain over the previous 2 hours. There are no clear changes
in the ECG. The nurse would expect which laboratory test to
provide confirmation of myocardial infarction (MI)?
a. Potassium of 5.2mEq/L
c. CK of 320 w/ MB of 12%
b.CK of 545 w/MB of 12%
d. WBC of 11,400/mm3

b. Soium level of 145 mEq/L

Rationale: B. A CK level above 150 with over 5% MB isoenzyme

indicates myocardial damage from AMI. Elevated potassium is not
indicative of myocardial infarction. Elevated WBC is an indicator of
many conditions, including MI.

5. The nurse is discharging a client to home with a new diagnosis

of atrial fibrillation. The nurse explains that which of the ff is the
most important symptoms to report to the physician?
a. Irregular pulse
c. fatigue
b. fever
d. hemoptysis

2. The nurse is caring for a client with history of HPN. The client is
being treated with metoprolol (Lopressor), hydrochlorothiazide
(Hydrodiuril), and captopril (Capoten). The client has a BP of
120/80 mmHg and a PR of 48. Which of the ff is the best action by
the nurse?
a. Administer the metoprolol (Lopressor) and hydrochlorothiazide
(Hydrodiuril), and hold the captopril (Capoten), and notify the
physician
b. Hold the metoprolol (Lopressor) and administer the
hydrochlorothiazide (Hydrodiuril), and the captopril (Capoten), and
notify the physician
c. Administer all the medications and notify the physician
d. Withhold all the medications and notify the physician
Rationale: B. The pt HR is bradycardic, and metoprolol, a betablocker, decreases the HR. Neither the captopril not the
hydrochlorothiazide lower HR, and either may be safely
administered to maintain control of the HPN. When a dose of
medication is withheld, it is the responsibility of the nurse to notify
the physician of the action and rationale.
3. The nurse has finished reviewing the shift report on the cardiac
unit. The nurse should plan to see which of the ff assigned pt first?
a. A pt with hypertrophic cardiomyopathy who is reporting dyspnea
b. A pt who has a cardiac catheterization and will be ambulating
for the first time
c. A client receiving antibiotics for bacterial endocarditis who is
reporting anxiety and chest pain
d. A client who is recovering from coronary artery bypass grafting
(CABG) surgery with a temperature of 101F
Rationale: C. A client with endocarditis is at risk for thrombus
formation, and chest pain and anxiety are signs of pulmonary
embolism (PE), which is life threatening complication requiring
immediate attention. Dyspnea is a chronic symptom of
hypertrophic cardiomyopathy, which requires assessment; a
temperature of 101F requires additional assessment, and a client
who is ambulating for the first time will be assessed by the nurse.
However, the pt who needs to be assessed for PE is not
emergent.
4. The nurse is caring for a pt with a history of renal failure and a
new MI. The nurse explains which of the ff is the most impt
symptom to the report the physician?
a. potassium level of 5.0mEq/L
c. Calcium level of 7.0mg/d L

d.Digoxin/digitalis level 0.8ng/mL

Rationale: Renal failure is a common cause of hypocalcemia, and

a value of 7.0mg/ d L is below the normal range of serum calcium.
Optiona A & B are within the upper limits for potassium and
sodium, ad option D is within the therapeutic range of digoxin

Rationale: D. A serious complication of AF is pulmonary embolism.

Irregular pulse is expected with AF. Fatigue may accompany AF in
some individuals. Fever is not associated with AF and is not
necessarily included in discharge teaching. However, it could be a
sign of illness that could increase the workload of the heart, and
therefore it would be the second-most important item to report if it
occurred.
6. The nurse is caring for a client who had just undergone cardiac
angiography. The catheter insertion site is free fro bleeding or
signs of hematoma. The VS and digital pulses remain in the pts
normal range. The IV fluids were discontinued. The pt is not
hungry or thirsty and refuses any food or fluids, asking to be left
alone to rest. Which of the ff is the nurses best response?
a. You are recovering well from the procedure and resting is a
good idea
b. t is important for you to walk, so I will be back in 1 hour to walk
with you
c. It is important to drink fluids after this procedure, to protect your
kidney function. I will bring you a pitcher of water, and I encourage
you to drink.
d. You will need to do the leg exercises that you practiced before
the procedure to keep good circulation to your legs. After your
exercises, you can rest
Rationale: C. The dye used in angiography is nephrotoxic, and a
client should have adequate fluids after the procedure to eliminate
the dye. The client should lie with the affected leg extended for 6
8 hours. Leg exercises are not recommended because exercise
could disrupt the clot that formed at the insertion site. Option A is
incorrect because it gives false reassurance to a client who could
be at risk it fluids are not taken in
7. The nurse is caring for a client with a diagnosis of aortic
stenosis. The client reports episodes of angina and passing our
recently at home. The client has surgery scheduled in 2 weeks.
Which of the ff would be the nurses best explanation about
activity at this time?
a. It is best time to avoid strenuous exercise, stairs, and lifting
before your surgery
b. Take short walks 3 times daily to prepare for postoperative
rehabilitation
c. There are no activity restrictions unless the angina reoccurs;
then please call the office

d. Gradually increase activity before surgery to build stamina for

the postoperative period
Rationale: A. Symptomatic aortic stenosis has a poor prognosis
without surgery. Restricting activity limits myocardial oxygen
consumption. Since the incidence of sudden death is high in this
population, it is prudent to decrease the strain on the heartwhile
awaiting surgery.
8.