,1. A client arrives in the emergency department with crushing substernal chest
pain radiating to the left arm. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer a stool softener
C. Encourage the client to ambulate
D. Schedule a stress test
Answer: A
Explanation: A 12-lead ECG should be obtained as quickly as possible when acute
coronary syndrome is suspected. Early identification of ST-segment changes helps
guide rapid treatment and improves outcomes.
2. A client with heart failure reports increasing shortness of breath when lying
flat. Which term best describes this symptom?
A. Orthopnea
B. Bradycardia
C. Syncope
D. Claudication
Answer: A
Explanation: Orthopnea is difficulty breathing when lying flat due to pulmonary
congestion. Clients with heart failure often sleep with multiple pillows or in a
recliner to relieve symptoms.
,3. Which assessment finding requires immediate intervention in a client
receiving intravenous heparin?
A. New onset of bloody urine
B. Mild bruising at an injection site
C. Heart rate of 78 beats/min
D. Blood pressure of 128/74 mm Hg
Answer: A
Explanation: Hematuria may indicate significant bleeding, a serious complication
of anticoagulant therapy. The nurse should notify the healthcare provider
promptly.
4. Which laboratory value is most specific for diagnosing myocardial injury?
A. Cardiac troponin
B. Hemoglobin
C. Serum sodium
D. White blood cell count
Answer: A
Explanation: Cardiac troponin is the preferred biomarker for detecting myocardial
injury because of its high sensitivity and specificity.
, 5. A client with heart failure is prescribed furosemide. Which finding best
indicates that the medication is effective?
A. Decreased bilateral lower-extremity edema
B. Increased appetite
C. Elevated temperature
D. Dry cough
Answer: A
Explanation: Furosemide promotes diuresis, reducing excess fluid accumulation
and improving edema and pulmonary congestion.
6. A client suddenly develops unilateral leg swelling, warmth, and calf
tenderness. Which condition should the nurse suspect first?
A. Deep vein thrombosis
B. Cellulitis
C. Osteoarthritis
D. Peripheral neuropathy
Answer: A
Explanation: Unilateral swelling, warmth, pain, and tenderness are classic
manifestations of deep vein thrombosis (DVT), which requires prompt evaluation.
pain radiating to the left arm. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer a stool softener
C. Encourage the client to ambulate
D. Schedule a stress test
Answer: A
Explanation: A 12-lead ECG should be obtained as quickly as possible when acute
coronary syndrome is suspected. Early identification of ST-segment changes helps
guide rapid treatment and improves outcomes.
2. A client with heart failure reports increasing shortness of breath when lying
flat. Which term best describes this symptom?
A. Orthopnea
B. Bradycardia
C. Syncope
D. Claudication
Answer: A
Explanation: Orthopnea is difficulty breathing when lying flat due to pulmonary
congestion. Clients with heart failure often sleep with multiple pillows or in a
recliner to relieve symptoms.
,3. Which assessment finding requires immediate intervention in a client
receiving intravenous heparin?
A. New onset of bloody urine
B. Mild bruising at an injection site
C. Heart rate of 78 beats/min
D. Blood pressure of 128/74 mm Hg
Answer: A
Explanation: Hematuria may indicate significant bleeding, a serious complication
of anticoagulant therapy. The nurse should notify the healthcare provider
promptly.
4. Which laboratory value is most specific for diagnosing myocardial injury?
A. Cardiac troponin
B. Hemoglobin
C. Serum sodium
D. White blood cell count
Answer: A
Explanation: Cardiac troponin is the preferred biomarker for detecting myocardial
injury because of its high sensitivity and specificity.
, 5. A client with heart failure is prescribed furosemide. Which finding best
indicates that the medication is effective?
A. Decreased bilateral lower-extremity edema
B. Increased appetite
C. Elevated temperature
D. Dry cough
Answer: A
Explanation: Furosemide promotes diuresis, reducing excess fluid accumulation
and improving edema and pulmonary congestion.
6. A client suddenly develops unilateral leg swelling, warmth, and calf
tenderness. Which condition should the nurse suspect first?
A. Deep vein thrombosis
B. Cellulitis
C. Osteoarthritis
D. Peripheral neuropathy
Answer: A
Explanation: Unilateral swelling, warmth, pain, and tenderness are classic
manifestations of deep vein thrombosis (DVT), which requires prompt evaluation.
