,Question 1
A nurse is caring for a client who reports sudden chest pain and shortness of breath. What is the
nurse's priority action?
A. Encourage the client to walk to relieve discomfort. B. Assess airway, breathing, circulation,
vital signs, and the characteristics of the pain. C. Offer a large meal to prevent weakness. D.
Delay assessment until the next scheduled medication round.
Correct Answer: B. Assess airway, breathing, circulation, vital signs, and the characteristics of
the pain.
Rationale: Sudden chest pain with shortness of breath may indicate acute coronary syndrome,
pulmonary embolism, or another life-threatening condition. The nurse should rapidly assess
physiological stability, activate emergency assistance when indicated, and initiate appropriate
monitoring and diagnostic evaluation. Ambulation and delays may worsen the situation.
Question 2
Which finding is most suggestive of left-sided heart failure?
A. Pulmonary crackles and shortness of breath. B. Isolated ankle injury. C. Increased appetite
without respiratory symptoms. D. Localized skin itching.
Correct Answer: A. Pulmonary crackles and shortness of breath.
Rationale: Left-sided heart failure can cause blood to back up into the pulmonary circulation,
resulting in pulmonary congestion, crackles, orthopnea, and dyspnea. Right-sided heart failure
more commonly causes systemic venous congestion, such as peripheral edema and jugular
venous distention. Findings may overlap, so the full assessment matters.
Question 3
A client with heart failure is prescribed daily weights. Which instruction should the nurse
provide?
A. Weigh at different times each day using different scales. B. Weigh every morning after
urinating, before breakfast, using the same scale and similar clothing. C. Weigh only when
shortness of breath develops. D. Record weight once per month.
Correct Answer: B. Weigh every morning after urinating, before breakfast, using the same scale
and similar clothing.
,Rationale: Consistent daily weights help detect fluid retention. A rapid increase may indicate
worsening heart failure and should be reported according to the client's care plan. The client
should follow their prescribed thresholds for contacting the healthcare team.
Question 4
A nurse is administering furosemide to a client with heart failure. Which laboratory value is
especially important to monitor?
A. Serum potassium. B. Hair color. C. Visual acuity alone. D. Blood type.
Correct Answer: A. Serum potassium.
Rationale: Furosemide is a loop diuretic that increases urinary excretion of sodium and water
and can also lower potassium. Hypokalemia may contribute to muscle weakness and dangerous
dysrhythmias. Monitoring should include electrolytes, renal function, blood pressure, fluid
status, and the client's response to treatment.
Question 5
A client with suspected myocardial infarction arrives in the emergency department. Which
diagnostic test is especially important for identifying myocardial injury?
A. Serum cardiac troponin testing. B. Urine color assessment alone. C. Routine hearing
screening. D. Skin allergy testing.
Correct Answer: A. Serum cardiac troponin testing.
Rationale: Cardiac troponins are biomarkers used to assess myocardial injury. Results must be
interpreted alongside symptoms, electrocardiogram findings, timing, and serial measurements
when indicated. Treatment of a suspected acute coronary syndrome should not be
unnecessarily delayed while awaiting laboratory results.
Question 6
A client with hypertension is prescribed an ACE inhibitor. Which adverse effect should the nurse
teach the client to report promptly?
A. Persistent dry cough. B. A temporary preference for cold drinks. C. Increased hair growth. D.
Mild hunger before meals.
Correct Answer: A. Persistent dry cough.
Rationale: ACE inhibitors, such as lisinopril, may cause a persistent dry cough. The nurse should
also teach the client to seek urgent care for swelling of the face, lips, or tongue because this
, may indicate angioedema. Blood pressure, kidney function, and potassium levels should be
monitored as prescribed.
Question 7
A nurse is assessing a client with peripheral arterial disease. Which finding is most
characteristic?
A. Leg discomfort during walking that improves with rest. B. Warm, swollen legs with brown skin
discoloration as the only possible finding. C. Pain that always disappears when the legs are
elevated. D. Bilateral ankle itching without circulation changes.
Correct Answer: A. Leg discomfort during walking that improves with rest.
Rationale: Intermittent claudication is a common manifestation of peripheral arterial disease. It
occurs when blood supply cannot meet the increased oxygen demand of exercising muscles.
The nurse should assess pulses, skin temperature, color, wounds, pain, and risk factors such as
smoking and diabetes.
Question 8
A client suddenly develops facial drooping, weakness in one arm, and difficulty speaking. What
should the nurse do first?
A. Allow the client to rest and reassess in two hours. B. Activate the stroke emergency response
and establish the time the client was last known well. C. Give food and water to assess
swallowing. D. Encourage the client to walk.
Correct Answer: B. Activate the stroke emergency response and establish the time the client
was last known well.
Rationale: Sudden facial drooping, arm weakness, and speech difficulty may indicate an acute
stroke. Rapid recognition and emergency evaluation are essential because some treatments are
time-sensitive. The nurse should determine the last-known-well time, monitor physiological
stability, and avoid oral intake until swallowing safety has been assessed.
Question 9
Which assessment finding in a client with deep vein thrombosis requires particular concern?
A. New shortness of breath and sudden chest pain. B. Mild thirst after exercise. C. A small bruise
on the forearm. D. Occasional sneezing.
Correct Answer: A. New shortness of breath and sudden chest pain.
A nurse is caring for a client who reports sudden chest pain and shortness of breath. What is the
nurse's priority action?
A. Encourage the client to walk to relieve discomfort. B. Assess airway, breathing, circulation,
vital signs, and the characteristics of the pain. C. Offer a large meal to prevent weakness. D.
Delay assessment until the next scheduled medication round.
Correct Answer: B. Assess airway, breathing, circulation, vital signs, and the characteristics of
the pain.
Rationale: Sudden chest pain with shortness of breath may indicate acute coronary syndrome,
pulmonary embolism, or another life-threatening condition. The nurse should rapidly assess
physiological stability, activate emergency assistance when indicated, and initiate appropriate
monitoring and diagnostic evaluation. Ambulation and delays may worsen the situation.
Question 2
Which finding is most suggestive of left-sided heart failure?
A. Pulmonary crackles and shortness of breath. B. Isolated ankle injury. C. Increased appetite
without respiratory symptoms. D. Localized skin itching.
Correct Answer: A. Pulmonary crackles and shortness of breath.
Rationale: Left-sided heart failure can cause blood to back up into the pulmonary circulation,
resulting in pulmonary congestion, crackles, orthopnea, and dyspnea. Right-sided heart failure
more commonly causes systemic venous congestion, such as peripheral edema and jugular
venous distention. Findings may overlap, so the full assessment matters.
Question 3
A client with heart failure is prescribed daily weights. Which instruction should the nurse
provide?
A. Weigh at different times each day using different scales. B. Weigh every morning after
urinating, before breakfast, using the same scale and similar clothing. C. Weigh only when
shortness of breath develops. D. Record weight once per month.
Correct Answer: B. Weigh every morning after urinating, before breakfast, using the same scale
and similar clothing.
,Rationale: Consistent daily weights help detect fluid retention. A rapid increase may indicate
worsening heart failure and should be reported according to the client's care plan. The client
should follow their prescribed thresholds for contacting the healthcare team.
Question 4
A nurse is administering furosemide to a client with heart failure. Which laboratory value is
especially important to monitor?
A. Serum potassium. B. Hair color. C. Visual acuity alone. D. Blood type.
Correct Answer: A. Serum potassium.
Rationale: Furosemide is a loop diuretic that increases urinary excretion of sodium and water
and can also lower potassium. Hypokalemia may contribute to muscle weakness and dangerous
dysrhythmias. Monitoring should include electrolytes, renal function, blood pressure, fluid
status, and the client's response to treatment.
Question 5
A client with suspected myocardial infarction arrives in the emergency department. Which
diagnostic test is especially important for identifying myocardial injury?
A. Serum cardiac troponin testing. B. Urine color assessment alone. C. Routine hearing
screening. D. Skin allergy testing.
Correct Answer: A. Serum cardiac troponin testing.
Rationale: Cardiac troponins are biomarkers used to assess myocardial injury. Results must be
interpreted alongside symptoms, electrocardiogram findings, timing, and serial measurements
when indicated. Treatment of a suspected acute coronary syndrome should not be
unnecessarily delayed while awaiting laboratory results.
Question 6
A client with hypertension is prescribed an ACE inhibitor. Which adverse effect should the nurse
teach the client to report promptly?
A. Persistent dry cough. B. A temporary preference for cold drinks. C. Increased hair growth. D.
Mild hunger before meals.
Correct Answer: A. Persistent dry cough.
Rationale: ACE inhibitors, such as lisinopril, may cause a persistent dry cough. The nurse should
also teach the client to seek urgent care for swelling of the face, lips, or tongue because this
, may indicate angioedema. Blood pressure, kidney function, and potassium levels should be
monitored as prescribed.
Question 7
A nurse is assessing a client with peripheral arterial disease. Which finding is most
characteristic?
A. Leg discomfort during walking that improves with rest. B. Warm, swollen legs with brown skin
discoloration as the only possible finding. C. Pain that always disappears when the legs are
elevated. D. Bilateral ankle itching without circulation changes.
Correct Answer: A. Leg discomfort during walking that improves with rest.
Rationale: Intermittent claudication is a common manifestation of peripheral arterial disease. It
occurs when blood supply cannot meet the increased oxygen demand of exercising muscles.
The nurse should assess pulses, skin temperature, color, wounds, pain, and risk factors such as
smoking and diabetes.
Question 8
A client suddenly develops facial drooping, weakness in one arm, and difficulty speaking. What
should the nurse do first?
A. Allow the client to rest and reassess in two hours. B. Activate the stroke emergency response
and establish the time the client was last known well. C. Give food and water to assess
swallowing. D. Encourage the client to walk.
Correct Answer: B. Activate the stroke emergency response and establish the time the client
was last known well.
Rationale: Sudden facial drooping, arm weakness, and speech difficulty may indicate an acute
stroke. Rapid recognition and emergency evaluation are essential because some treatments are
time-sensitive. The nurse should determine the last-known-well time, monitor physiological
stability, and avoid oral intake until swallowing safety has been assessed.
Question 9
Which assessment finding in a client with deep vein thrombosis requires particular concern?
A. New shortness of breath and sudden chest pain. B. Mild thirst after exercise. C. A small bruise
on the forearm. D. Occasional sneezing.
Correct Answer: A. New shortness of breath and sudden chest pain.
