COMPREHENSIVE TEST BANK: CLINICAL REASONING CASES IN NURSING, 8TH
EDITION
BY MARIANN M. HARDING & JULIE S. SNYDER
VERIFIED CHAPTERS 1–15 | NCLEX-STYLE QUESTIONS WITH DETAILED RATIONALES
SECTION 1: PERFUSION (QUESTIONS 1–20)
1. The nurse is explaining impaired central perfusion to a student nurse. The student
demonstrates understanding by stating that central perfusion:
A. Is monitored only by the physician
B. Involves the entire body
C. Is decreased with hypertension
D. Is toxic to the cardiac system
Answer: B – Central perfusion involves the entire body as all organs are supplied with
oxygen and vital nutrients. The physician does not control the body's ability for perfusion.
Central perfusion is not decreased with hypertension, nor is it toxic to the cardiac system.
2. A patient diagnosed with hypertension asks how this disease could have happened.
The nurse's best response is that hypertension:
A. Happens to everyone sooner or later
B. Can happen from eating a poor diet
C. Can happen from arterial changes that impede blood flow
D. Happens when people do not exercise
Answer: C – Hardening of the arteries from atherosclerosis can cause hypertension.
Hypertension does not happen to everyone. While diet and exercise changes may be
positive, these responses do not explain the underlying pathophysiology.
3. The patient asks the nurse to explain the sinoatrial node. The nurse's best response
is that the sinoatrial node:
A. Provides the heart with stimulation to beat in a normal rhythm
B. Protects the heart from atherosclerotic changes
C. Provides the heart with oxygenated blood
D. Protects the heart from infection
,Answer: A – The sinoatrial node is the natural pacemaker of the heart and assists the heart
to beat in a normal rhythm. It does not protect from atherosclerotic changes or infection,
nor does it directly provide oxygenated blood.
4. A patient with internal bleeding from a motor vehicle accident is brought to the
emergency department. The nurse's primary concern is to monitor for:
A. Mental alertness
B. Perfusion
C. Pain
D. Reaction to medications
Answer: B – Perfusion is the primary concern with internal bleeding; the nurse should
monitor vital signs to ensure adequate perfusion. Mental alertness, pain, and medication
reactions are important but not the primary concern.
5. The nurse is caring for a patient with acute decompensated heart failure. Which
assessment finding is the earliest indicator of worsening perfusion?
A. Jugular venous distention
B. Weight gain of 2 kg over 24 hours
C. Decreased urine output to 20 mL/hour
D. Orthopnea requiring three pillows
Answer: C – Decreased urine output (<30 mL/hour) is an early sign of reduced renal
perfusion due to declining cardiac output. JVD, weight gain, and orthopnea indicate fluid
overload but are later signs of worsening heart failure.
6. A patient with peripheral artery disease reports calf pain when walking that resolves
with rest. The nurse documents this finding as:
A. Rest pain
B. Intermittent claudication
C. Venous insufficiency
D. Neuropathic pain
Answer: B – Intermittent claudication is reproducible ischemic muscle pain that occurs
with exercise and resolves within minutes of rest. Rest pain indicates severe PAD. Venous
insufficiency causes leg heaviness and edema.
7. The nurse is administering IV furosemide to a patient with pulmonary edema. Which
assessment finding indicates the medication is having the desired effect?
A. Blood pressure increases from 90/60 to 110/70 mmHg
B. Urine output increases to 150 mL over 2 hours
,C. Heart rate decreases from 120 to 110 bpm
D. Oxygen saturation remains at 88%
Answer: B – Furosemide is a loop diuretic; the desired effect is diuresis (increased urine
output) to reduce preload and relieve pulmonary congestion. Increased BP and decreased
HR are secondary effects.
8. A patient with chronic venous insufficiency has bilateral lower extremity edema and
brownish discoloration above the ankles. Which intervention is most important?
A. Elevate legs above heart level
B. Apply graduated compression stockings
C. Administer diuretics as ordered
D. Encourage daily walking
Answer: B – Compression stockings are the mainstay of treatment for venous insufficiency,
reducing edema and preventing skin changes. Elevation helps but is not as effective as
compression.
9. The nurse is auscultating heart sounds and hears an S3 gallop. This finding is most
commonly associated with:
A. Mitral valve prolapse
B. Aortic stenosis
C. Heart failure
D. Pericarditis
Answer: C – An S3 gallop is most commonly associated with heart failure, indicating
increased ventricular filling pressure and volume overload.
10. A patient's serum potassium level is low. The nurse knows the patient should be
observed for:
A. Tissue ischemia
B. Brain malformations
C. Intestinal blockage
D. Cardiac dysrhythmia
Answer: D – Cardiac dysrhythmia is a possibility when serum potassium is high or low.
Tissue ischemia, brain malformations, or intestinal blockage do not have a direct
correlation to potassium irregularities.
11. The nurse is performing a general survey. Which action is a component of the
general survey?
A. Observing the patient's body stature and nutritional status
, B. Interpreting the subjective information the patient has reported
C. Measuring the patient's temperature, pulse, respirations, and blood pressure
D. Observing specific body systems while performing the physical assessment
Answer: A – Observing body stature and nutritional status is a component of the general
survey. Interpreting subjective information, measuring vital signs, and observing specific
body systems are part of other assessment components.
12. When measuring a patient's weight, the nurse is aware of which guideline?
A. The patient is always weighed wearing only undergarments
B. The type of scale does not matter as long as weights are similar
C. The patient may leave on jacket and shoes as long as documented
D. Attempts should be made to weigh at approximately the same time of day
Answer: D – Attempts should be made to weigh the patient at approximately the same time
of day if a sequence of weights is necessary for accuracy and consistency.
13. A patient's weekly blood pressure readings for 2 months have ranged between
124/84 mm Hg and 136/88 mm Hg, with an average of 126/86 mm Hg. This blood
pressure falls within which category?
A. Normal blood pressure
B. Prehypertension
C. Stage 1 hypertension
D. Stage 2 hypertension
Answer: B – These readings fall within the prehypertension category (systolic 120–139 or
diastolic 80–89).
14. When evaluating the temperature of older adults, the nurse should remember that:
A. Body temperature of the older adult is lower than that of a younger adult
B. An older adult's body temperature is approximately the same as a young child
C. Body temperature depends on the type of thermometer used
D. In the older adult, body temperature varies widely
Answer: A – The body temperature of the older adult is lower than that of a younger adult
due to age-related changes in thermoregulation.
15. A patient with hypertension is prescribed an angiotensin-converting enzyme (ACE)
inhibitor. The nurse should monitor for which potential adverse effect?
A. Hyperkalemia
B. Hypokalemia
EDITION
BY MARIANN M. HARDING & JULIE S. SNYDER
VERIFIED CHAPTERS 1–15 | NCLEX-STYLE QUESTIONS WITH DETAILED RATIONALES
SECTION 1: PERFUSION (QUESTIONS 1–20)
1. The nurse is explaining impaired central perfusion to a student nurse. The student
demonstrates understanding by stating that central perfusion:
A. Is monitored only by the physician
B. Involves the entire body
C. Is decreased with hypertension
D. Is toxic to the cardiac system
Answer: B – Central perfusion involves the entire body as all organs are supplied with
oxygen and vital nutrients. The physician does not control the body's ability for perfusion.
Central perfusion is not decreased with hypertension, nor is it toxic to the cardiac system.
2. A patient diagnosed with hypertension asks how this disease could have happened.
The nurse's best response is that hypertension:
A. Happens to everyone sooner or later
B. Can happen from eating a poor diet
C. Can happen from arterial changes that impede blood flow
D. Happens when people do not exercise
Answer: C – Hardening of the arteries from atherosclerosis can cause hypertension.
Hypertension does not happen to everyone. While diet and exercise changes may be
positive, these responses do not explain the underlying pathophysiology.
3. The patient asks the nurse to explain the sinoatrial node. The nurse's best response
is that the sinoatrial node:
A. Provides the heart with stimulation to beat in a normal rhythm
B. Protects the heart from atherosclerotic changes
C. Provides the heart with oxygenated blood
D. Protects the heart from infection
,Answer: A – The sinoatrial node is the natural pacemaker of the heart and assists the heart
to beat in a normal rhythm. It does not protect from atherosclerotic changes or infection,
nor does it directly provide oxygenated blood.
4. A patient with internal bleeding from a motor vehicle accident is brought to the
emergency department. The nurse's primary concern is to monitor for:
A. Mental alertness
B. Perfusion
C. Pain
D. Reaction to medications
Answer: B – Perfusion is the primary concern with internal bleeding; the nurse should
monitor vital signs to ensure adequate perfusion. Mental alertness, pain, and medication
reactions are important but not the primary concern.
5. The nurse is caring for a patient with acute decompensated heart failure. Which
assessment finding is the earliest indicator of worsening perfusion?
A. Jugular venous distention
B. Weight gain of 2 kg over 24 hours
C. Decreased urine output to 20 mL/hour
D. Orthopnea requiring three pillows
Answer: C – Decreased urine output (<30 mL/hour) is an early sign of reduced renal
perfusion due to declining cardiac output. JVD, weight gain, and orthopnea indicate fluid
overload but are later signs of worsening heart failure.
6. A patient with peripheral artery disease reports calf pain when walking that resolves
with rest. The nurse documents this finding as:
A. Rest pain
B. Intermittent claudication
C. Venous insufficiency
D. Neuropathic pain
Answer: B – Intermittent claudication is reproducible ischemic muscle pain that occurs
with exercise and resolves within minutes of rest. Rest pain indicates severe PAD. Venous
insufficiency causes leg heaviness and edema.
7. The nurse is administering IV furosemide to a patient with pulmonary edema. Which
assessment finding indicates the medication is having the desired effect?
A. Blood pressure increases from 90/60 to 110/70 mmHg
B. Urine output increases to 150 mL over 2 hours
,C. Heart rate decreases from 120 to 110 bpm
D. Oxygen saturation remains at 88%
Answer: B – Furosemide is a loop diuretic; the desired effect is diuresis (increased urine
output) to reduce preload and relieve pulmonary congestion. Increased BP and decreased
HR are secondary effects.
8. A patient with chronic venous insufficiency has bilateral lower extremity edema and
brownish discoloration above the ankles. Which intervention is most important?
A. Elevate legs above heart level
B. Apply graduated compression stockings
C. Administer diuretics as ordered
D. Encourage daily walking
Answer: B – Compression stockings are the mainstay of treatment for venous insufficiency,
reducing edema and preventing skin changes. Elevation helps but is not as effective as
compression.
9. The nurse is auscultating heart sounds and hears an S3 gallop. This finding is most
commonly associated with:
A. Mitral valve prolapse
B. Aortic stenosis
C. Heart failure
D. Pericarditis
Answer: C – An S3 gallop is most commonly associated with heart failure, indicating
increased ventricular filling pressure and volume overload.
10. A patient's serum potassium level is low. The nurse knows the patient should be
observed for:
A. Tissue ischemia
B. Brain malformations
C. Intestinal blockage
D. Cardiac dysrhythmia
Answer: D – Cardiac dysrhythmia is a possibility when serum potassium is high or low.
Tissue ischemia, brain malformations, or intestinal blockage do not have a direct
correlation to potassium irregularities.
11. The nurse is performing a general survey. Which action is a component of the
general survey?
A. Observing the patient's body stature and nutritional status
, B. Interpreting the subjective information the patient has reported
C. Measuring the patient's temperature, pulse, respirations, and blood pressure
D. Observing specific body systems while performing the physical assessment
Answer: A – Observing body stature and nutritional status is a component of the general
survey. Interpreting subjective information, measuring vital signs, and observing specific
body systems are part of other assessment components.
12. When measuring a patient's weight, the nurse is aware of which guideline?
A. The patient is always weighed wearing only undergarments
B. The type of scale does not matter as long as weights are similar
C. The patient may leave on jacket and shoes as long as documented
D. Attempts should be made to weigh at approximately the same time of day
Answer: D – Attempts should be made to weigh the patient at approximately the same time
of day if a sequence of weights is necessary for accuracy and consistency.
13. A patient's weekly blood pressure readings for 2 months have ranged between
124/84 mm Hg and 136/88 mm Hg, with an average of 126/86 mm Hg. This blood
pressure falls within which category?
A. Normal blood pressure
B. Prehypertension
C. Stage 1 hypertension
D. Stage 2 hypertension
Answer: B – These readings fall within the prehypertension category (systolic 120–139 or
diastolic 80–89).
14. When evaluating the temperature of older adults, the nurse should remember that:
A. Body temperature of the older adult is lower than that of a younger adult
B. An older adult's body temperature is approximately the same as a young child
C. Body temperature depends on the type of thermometer used
D. In the older adult, body temperature varies widely
Answer: A – The body temperature of the older adult is lower than that of a younger adult
due to age-related changes in thermoregulation.
15. A patient with hypertension is prescribed an angiotensin-converting enzyme (ACE)
inhibitor. The nurse should monitor for which potential adverse effect?
A. Hyperkalemia
B. Hypokalemia
