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Adult Health Nursing II Exam 2 & 3 — Practice Questions with Detailed
Rationales Cardiac, Burns & Trauma | 2026–2027 Edition
SECTION 1: ACUTE MYOCARDIAL INFARCTION & ADVANCED
CARDIAC DISORDERS — Questions
Q1. A client presents to the emergency department with
crushing substernal chest pain radiating to the left arm,
diaphoresis, and nausea. Which initial action is the priority?
A. Obtain a 12-lead ECG within 10 minutes
B. Administer aspirin 325 mg chewed
C. Establish IV access
D. Obtain serum troponin levels
Answer: A
Rationale: The priority is obtaining a 12-lead ECG within 10
minutes of arrival to identify STEMI and determine the need for
reperfusion therapy. While aspirin and IV access are important,
the ECG guides immediate treatment decisions.
Q2. A client with STEMI is prescribed fibrinolytic therapy. Which
finding is an absolute contraindication?
A. Blood pressure 160/90 mmHg
B. History of ischemic stroke 2 years ago
C. Recent warfarin use with INR 1.5
D. Active internal bleeding
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Answer: D
Rationale: Active internal bleeding is an absolute
contraindication to fibrinolytic therapy. Other absolute
contraindications include prior intracranial hemorrhage, known
structural cerebral vascular lesion, and ischemic stroke within 3
months.
Q3. A client receiving alteplase for STEMI develops sudden
severe headache and confusion. What is the priority nursing
action?
A. Continue the infusion and monitor
B. Stop the infusion and notify the provider immediately
C. Administer acetaminophen for headache
D. Elevate the head of the bed
Answer: B
Rationale: Sudden severe headache and confusion during
fibrinolytic therapy suggest intracranial hemorrhage. The
infusion must be stopped immediately, and the provider
notified.
Q4. Which biomarker is most specific for myocardial injury?
A. CK-MB
B. Troponin I
C. Myoglobin
D. LDH
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Answer: B
Rationale: Troponin I is the most specific and sensitive
biomarker for myocardial injury. It rises within 3–6 hours and
remains elevated for 7–10 days.
Q5. A client with acute MI is prescribed morphine sulfate.
Which assessment finding requires holding the medication?
A. Respiratory rate 10/min
B. Pain rating 8/10
C. Blood pressure 130/80 mmHg
D. Heart rate 90 bpm
Answer: A
Rationale: Morphine can cause respiratory depression. A
respiratory rate of 10/min is borderline and requires holding
the medication and notifying the provider.
Q6. A client with acute MI develops ventricular fibrillation.
What is the priority intervention?
A. Administer amiodarone IV push
B. Begin CPR and defibrillate
C. Administer epinephrine IV push
D. Perform synchronized cardioversion
Answer: B
Rationale: Ventricular fibrillation is a shockable rhythm. The
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priority is immediate defibrillation and CPR. Time is critical for
survival.
Q7. A client with acute MI is prescribed nitroglycerin IV. Which
finding requires immediate intervention?
A. Blood pressure 140/90 mmHg
B. Blood pressure 85/55 mmHg
C. Heart rate 100 bpm
D. Pain rating 6/10
Answer: B
Rationale: Nitroglycerin causes vasodilation and can cause
hypotension. A systolic BP <90 mmHg requires holding the
medication and notifying the provider.
Q8. Which client is at highest risk for acute myocardial
infarction?
A. 35-year-old with well-controlled asthma
B. 55-year-old with diabetes, hypertension, and smoking history
C. 25-year-old with seasonal allergies
D. 45-year-old with well-controlled hypothyroidism
Answer: B
Rationale: Diabetes, hypertension, and smoking are major
modifiable risk factors for coronary artery disease and MI.
Adult Health Nursing II Exam 2 & 3 — Practice Questions with Detailed
Rationales Cardiac, Burns & Trauma | 2026–2027 Edition
SECTION 1: ACUTE MYOCARDIAL INFARCTION & ADVANCED
CARDIAC DISORDERS — Questions
Q1. A client presents to the emergency department with
crushing substernal chest pain radiating to the left arm,
diaphoresis, and nausea. Which initial action is the priority?
A. Obtain a 12-lead ECG within 10 minutes
B. Administer aspirin 325 mg chewed
C. Establish IV access
D. Obtain serum troponin levels
Answer: A
Rationale: The priority is obtaining a 12-lead ECG within 10
minutes of arrival to identify STEMI and determine the need for
reperfusion therapy. While aspirin and IV access are important,
the ECG guides immediate treatment decisions.
Q2. A client with STEMI is prescribed fibrinolytic therapy. Which
finding is an absolute contraindication?
A. Blood pressure 160/90 mmHg
B. History of ischemic stroke 2 years ago
C. Recent warfarin use with INR 1.5
D. Active internal bleeding
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Answer: D
Rationale: Active internal bleeding is an absolute
contraindication to fibrinolytic therapy. Other absolute
contraindications include prior intracranial hemorrhage, known
structural cerebral vascular lesion, and ischemic stroke within 3
months.
Q3. A client receiving alteplase for STEMI develops sudden
severe headache and confusion. What is the priority nursing
action?
A. Continue the infusion and monitor
B. Stop the infusion and notify the provider immediately
C. Administer acetaminophen for headache
D. Elevate the head of the bed
Answer: B
Rationale: Sudden severe headache and confusion during
fibrinolytic therapy suggest intracranial hemorrhage. The
infusion must be stopped immediately, and the provider
notified.
Q4. Which biomarker is most specific for myocardial injury?
A. CK-MB
B. Troponin I
C. Myoglobin
D. LDH
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Answer: B
Rationale: Troponin I is the most specific and sensitive
biomarker for myocardial injury. It rises within 3–6 hours and
remains elevated for 7–10 days.
Q5. A client with acute MI is prescribed morphine sulfate.
Which assessment finding requires holding the medication?
A. Respiratory rate 10/min
B. Pain rating 8/10
C. Blood pressure 130/80 mmHg
D. Heart rate 90 bpm
Answer: A
Rationale: Morphine can cause respiratory depression. A
respiratory rate of 10/min is borderline and requires holding
the medication and notifying the provider.
Q6. A client with acute MI develops ventricular fibrillation.
What is the priority intervention?
A. Administer amiodarone IV push
B. Begin CPR and defibrillate
C. Administer epinephrine IV push
D. Perform synchronized cardioversion
Answer: B
Rationale: Ventricular fibrillation is a shockable rhythm. The
, Page |4
priority is immediate defibrillation and CPR. Time is critical for
survival.
Q7. A client with acute MI is prescribed nitroglycerin IV. Which
finding requires immediate intervention?
A. Blood pressure 140/90 mmHg
B. Blood pressure 85/55 mmHg
C. Heart rate 100 bpm
D. Pain rating 6/10
Answer: B
Rationale: Nitroglycerin causes vasodilation and can cause
hypotension. A systolic BP <90 mmHg requires holding the
medication and notifying the provider.
Q8. Which client is at highest risk for acute myocardial
infarction?
A. 35-year-old with well-controlled asthma
B. 55-year-old with diabetes, hypertension, and smoking history
C. 25-year-old with seasonal allergies
D. 45-year-old with well-controlled hypothyroidism
Answer: B
Rationale: Diabetes, hypertension, and smoking are major
modifiable risk factors for coronary artery disease and MI.
