SECTION 1: CARDIOVASCULAR SYSTEM
QUESTION 1
A nurse is assessing a client with acute decompensated heart failure (ADHF). Which
finding is most concerning?
A) +2 pitting edema in lower extremities
B) Jugular venous distension (JVD) at 45 degrees
C) Paroxysmal nocturnal dyspnea (PND)
D) Crackles audible to the midscapular region
ANSWER: D
RATIONALE: Crackles that extend to the midscapular region indicate that pulmonary
edema is severe and widespread, signifying imminent respiratory compromise. While
peripheral edema, JVD, and PND are important signs of fluid overload, they are not as
immediately life-threatening as extensive pulmonary edema.
QUESTION 2
A client with infective endocarditis develops sudden left-sided weakness and slurred
speech. What is the priority action?
A) Administer aspirin 325 mg PO
B) Obtain a STAT CT scan of the head
C) Check blood glucose level
D) Reorient the client to person, place, time
ANSWER: B
RATIONALE: The client is likely experiencing an embolic stroke from a vegetation
, fragment. A STAT CT scan is required to rule out hemorrhage before any thrombolytics
or anticoagulation can be considered.
QUESTION 3
A client presents with chest pain radiating to the left arm, diaphoresis, and nausea.
Which medication should the nurse anticipate administering first?
A) Morphine
B) Nitroglycerin
C) Aspirin
D) Oxygen
ANSWER: C
RATIONALE: Aspirin should be administered immediately upon suspicion of myocardial
infarction (MI) due to its antiplatelet effects. While the MONA protocol (Morphine,
Oxygen, Nitroglycerin, Aspirin) is standard, aspirin is the priority to prevent further clot
formation.
QUESTION 4
Which of the following is a classic symptom of left-sided heart failure?
A) Peripheral edema
B) Ascites
C) Dyspnea and crackles
D) Jugular venous distension
ANSWER: C
RATIONALE: Left-sided heart failure results in pulmonary symptoms including dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, and crackles due to fluid backing up into the
QUESTION 1
A nurse is assessing a client with acute decompensated heart failure (ADHF). Which
finding is most concerning?
A) +2 pitting edema in lower extremities
B) Jugular venous distension (JVD) at 45 degrees
C) Paroxysmal nocturnal dyspnea (PND)
D) Crackles audible to the midscapular region
ANSWER: D
RATIONALE: Crackles that extend to the midscapular region indicate that pulmonary
edema is severe and widespread, signifying imminent respiratory compromise. While
peripheral edema, JVD, and PND are important signs of fluid overload, they are not as
immediately life-threatening as extensive pulmonary edema.
QUESTION 2
A client with infective endocarditis develops sudden left-sided weakness and slurred
speech. What is the priority action?
A) Administer aspirin 325 mg PO
B) Obtain a STAT CT scan of the head
C) Check blood glucose level
D) Reorient the client to person, place, time
ANSWER: B
RATIONALE: The client is likely experiencing an embolic stroke from a vegetation
, fragment. A STAT CT scan is required to rule out hemorrhage before any thrombolytics
or anticoagulation can be considered.
QUESTION 3
A client presents with chest pain radiating to the left arm, diaphoresis, and nausea.
Which medication should the nurse anticipate administering first?
A) Morphine
B) Nitroglycerin
C) Aspirin
D) Oxygen
ANSWER: C
RATIONALE: Aspirin should be administered immediately upon suspicion of myocardial
infarction (MI) due to its antiplatelet effects. While the MONA protocol (Morphine,
Oxygen, Nitroglycerin, Aspirin) is standard, aspirin is the priority to prevent further clot
formation.
QUESTION 4
Which of the following is a classic symptom of left-sided heart failure?
A) Peripheral edema
B) Ascites
C) Dyspnea and crackles
D) Jugular venous distension
ANSWER: C
RATIONALE: Left-sided heart failure results in pulmonary symptoms including dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, and crackles due to fluid backing up into the
