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1. A nurse is assessing a client with left-sided heart failure. Which
symptom is most commonly associated with this condition?
A. Peripheral edema B. Jugular vein distention C. Pulmonary
crackles D. Hepatomegaly
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes blood to back up into the
lungs, leading to pulmonary congestion and crackles on auscultation.
Peripheral edema, jugular vein distention, and hepatomegaly are more
commonly associated with right-sided heart failure.
2. Which laboratory value is most important for the nurse to
monitor in a client receiving warfarin therapy?
A. Platelet count B. INR C. Hemoglobin D. Potassium
Answer: B. INR
Rationale: The international normalized ratio (INR) is used to monitor
the effectiveness and safety of warfarin therapy. Therapeutic INR
levels help prevent clot formation while minimizing bleeding risk.
3. A client reports chest pain relieved by rest. The nurse
recognizes this finding as most consistent with:
,A. Unstable angina B. Myocardial infarction C. Stable angina D.
Pericarditis
Answer: C. Stable angina
Rationale: Stable angina typically occurs with exertion and is relieved
by rest or nitroglycerin. Unstable angina is more severe and
unpredictable, while myocardial infarction pain is usually not relieved
by rest.
4. Which assessment finding requires immediate nursing
intervention in a client receiving digoxin?
A. Apical pulse of 58 beats/minute B. Blood pressure of 128/76 mm
Hg C. Respiratory rate of 18 breaths/minute D. Potassium level of
4.2 mEq/L
Answer: A. Apical pulse of 58 beats/minute
Rationale: Digoxin can cause bradycardia. The nurse should withhold
the medication and notify the healthcare provider if the apical pulse is
below 60 beats/minute.
5. A nurse is caring for a client with hypertension. Which lifestyle
modification should the nurse encourage?
A. Increased sodium intake B. Sedentary activity C. Weight
reduction D. Smoking continuation
Answer: C. Weight reduction
Rationale: Weight reduction helps decrease blood pressure and
reduces cardiovascular risk. Increased sodium intake, smoking, and
inactivity contribute to hypertension.
6. Which client is at greatest risk for developing infective
endocarditis?
,A. A client with osteoarthritis B. A client with a prosthetic heart
valve C. A client with seasonal allergies D. A client with migraine
headaches
Answer: B. A client with a prosthetic heart valve
Rationale: Prosthetic heart valves increase the risk for infective
endocarditis because bacteria can adhere to artificial surfaces within
the heart.
7. A nurse is teaching a client about nitroglycerin tablets. Which
statement by the client indicates correct understanding?
A. “I will store the tablets in the bathroom.” B. “I will take one
tablet every hour for chest pain.” C. “I should sit down before
taking the medication.” D. “I can leave the bottle open for
convenience.”
Answer: C. “I should sit down before taking the medication.”
Rationale: Nitroglycerin can cause hypotension and dizziness, so
clients should sit or lie down before taking it. The medication should
be stored in a dark, tightly closed container away from heat and
moisture.
8. Which electrolyte imbalance places a client at highest risk for
cardiac dysrhythmias?
A. Hypercalcemia B. Hypokalemia C. Hypermagnesemia D.
Hyponatremia
Answer: B. Hypokalemia
Rationale: Low potassium levels can interfere with cardiac conduction
and increase the risk of dangerous dysrhythmias.
, 9. A client with atrial fibrillation is prescribed anticoagulant
therapy primarily to prevent:
A. Hypertension B. Heart failure C. Stroke D. Angina
Answer: C. Stroke
Rationale: Atrial fibrillation increases the risk of blood clot formation
in the atria, which can travel to the brain and cause a stroke.
10. Which food should a client taking warfarin consume
consistently?
A. Spinach B. Bananas C. Chicken D. Rice
Answer: A. Spinach
Rationale: Spinach contains vitamin K, which affects warfarin
activity. Clients should maintain consistent vitamin K intake to avoid
fluctuations in INR levels.
11. A nurse is caring for a client experiencing a myocardial
infarction. Which cardiac biomarker is most specific for
myocardial injury?
A. Creatinine kinase B. Troponin C. Myoglobin D. BNP
Answer: B. Troponin
Rationale: Troponin is highly specific for myocardial muscle damage
and is the preferred biomarker for diagnosing myocardial infarction.
12. Which intervention is most important when caring for a
client with acute chest pain?
A. Encouraging ambulation B. Administering oxygen as prescribed
C. Increasing oral fluids D. Placing the client in Trendelenburg
position