Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A client reports chest pain that radiates to the left arm and jaw. What is the priority nursing
action?
A. Ask the client to rate the pain on a scale of 0 to 10
✔✔B. Apply oxygen and obtain vital signs
C. Notify the provider immediately
D. Reassure the client and offer water
A nurse is performing a cardiovascular assessment. Which of the following is a normal finding?
✔✔A. PMI located at the fifth intercostal space, midclavicular line
B. Jugular vein distension at 30 degrees elevation
C. S3 heart sound in an adult over 50
D. Capillary refill greater than 3 seconds
Which laboratory value should the nurse report immediately for a client with suspected
myocardial infarction?
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,✔✔A. Troponin I level of 3.5 ng/mL
B. Total cholesterol level of 180 mg/dL
C. LDL level of 110 mg/dL
D. Hemoglobin level of 13.5 g/dL
During a cardiovascular assessment, the nurse hears a murmur. What is the best action?
A. Document the finding as normal
✔✔B. Notify the healthcare provider for further evaluation
C. Ask the client to cough and reassess
D. Apply oxygen immediately
A client with heart failure reports difficulty breathing while lying flat. What term describes this
condition?
✔✔A. Orthopnea
B. Dyspnea on exertion
C. Paroxysmal nocturnal dyspnea
D. Tachypnea
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, Which of the following is an expected finding when assessing peripheral circulation?
✔✔A. Warm skin with palpable dorsalis pedis pulses
B. Cool extremities with absent pedal pulses
C. Bilateral pitting edema in lower extremities
D. Delayed capillary refill and cyanotic toes
What should the nurse assess first in a client who is diaphoretic, anxious, and has a BP of 86/52
mm Hg?
✔✔A. Heart rate and rhythm
B. Capillary refill time
C. Bowel sounds
D. Skin turgor
Which finding during auscultation requires immediate attention?
A. S1 and S2 heart sounds
✔✔B. New-onset S4 sound in an adult client
C. Slight variation in rhythm during respiration
D. Soft systolic murmur in a child
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