NUR 213 Test #2 Questions with All
Correct Answers Rated A+ 2025
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional
assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min - Answer a. Heart rate of 120 beats/min
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure
decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect
on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This
tachycardia is an early response and is seen even when blood pressure is not critically low. An
increased heart rate and respiratory rate will compensate for the low blood pressure and
maintain oxygen saturations and perfusion. The client may not be able to compensate for long,
and decreased oxygenation and cool, clammy skin will occur later.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment
should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min - Answer d. Pulse decreased from 100
beats/min to 80 beats/min
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic
(fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR
and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-
adrenergic receptor sites. Cardiac output will drop because of decreased HR.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as
having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
,The incidence of coronary artery disease and hypertension is higher in American Indians than in
whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary
artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone
therapy do not increase risk for cardiovascular disease.
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate
is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client's medications.
d. Administer 1 mg of atropine. - Answer c. Assess the client's medications.
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in
bradycardia. The nurse should check the medication reconciliation for medications that might
cause such a drop in heart rate, then should inform the health care provider. Documentation is
important, but it is not the priority action. The heart rate is not low enough for atropine or an
external pacemaker to be needed.
An emergency room nurse obtains the health history of a client. Which statement by the client
should alert the nurse to the occurrence of heart failure?
a. "I get short of breath when I climb stairs."
b. "I see halos floating around my head."
c. "I have trouble remembering things."
d. "I have lost weight over the past month." - Answer a. "I get short of breath when I climb
stairs."
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity
such as stair climbing. The other findings are not specific to early occurrence of heart failure.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which
statement by the client should alert the nurse to the presence of edema?
a. "I wake up to go to the bathroom at night."
b. "My shoes fit tighter by the end of the day."
c. "I seem to be feeling more anxious lately."
,Weight gain can result from fluid accumulation in the interstitial spaces. This is known as
edema. The nurse should note whether the client feels that his or her shoes or rings are tight,
and should observe, when present, an indentation around the leg where the socks end. The
other answers do not describe edema.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical
manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm - Answer c. Disorientation and confusion
In older adults, disorientation or confusion may be the major manifestation of myocardial
infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the
arm could also be related to the myocardial infarction. However, the nurse should be more
concerned about the new onset of disorientation or confusion caused by decreased perfusion.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The
nurse notes that the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as "left pedal pulse of +1/4." - Answer c. Assess the color and
temperature of the left leg.
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial
obstruction. The pulse may be faint because of edema. The left pulse should be compared with
the right, and pulses should be compared with previous assessments, especially before the
procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease
in circulation. Once all peripheral and vascular assessment data are acquired, the primary health
care provider should be notified. Simply documenting the findings is inappropriate. The leg
should be positioned below the level of the heart or dangling to increase blood flow to the
distal portion of the leg. Increasing intravenous fluids will not address the client's problem.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which
assessment finding requires immediate intervention?
a. Urinary output less than intake
, A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident.
A change in neurologic status needs to be acted on immediately. Discomfort and bruising are
expected at the site. If intake decreases, a client can become dehydrated because of dye
excretion. The second intervention would be to increase the client's fluid status. Neurologic
changes would take priority.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment
should the nurse complete prior to this procedure?
a. Client's level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents - Answer d. Allergies to iodine-based agents
Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-
containing preparations, such as seafood or local anesthetics. The contrast medium used during
the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high
priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac
status.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The
client's health history includes a previous myocardial infarction and pacemaker implantation.
Which action should the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI. - Answer b. Notify the
health care provider before scheduling the MRI.
The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health
care provider and report that the client has a pacemaker so the provider can order other
diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased
fluids.
A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary
artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
Correct Answers Rated A+ 2025
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional
assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min - Answer a. Heart rate of 120 beats/min
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure
decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect
on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This
tachycardia is an early response and is seen even when blood pressure is not critically low. An
increased heart rate and respiratory rate will compensate for the low blood pressure and
maintain oxygen saturations and perfusion. The client may not be able to compensate for long,
and decreased oxygenation and cool, clammy skin will occur later.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment
should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min - Answer d. Pulse decreased from 100
beats/min to 80 beats/min
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic
(fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR
and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-
adrenergic receptor sites. Cardiac output will drop because of decreased HR.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as
having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
,The incidence of coronary artery disease and hypertension is higher in American Indians than in
whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary
artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone
therapy do not increase risk for cardiovascular disease.
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate
is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client's medications.
d. Administer 1 mg of atropine. - Answer c. Assess the client's medications.
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in
bradycardia. The nurse should check the medication reconciliation for medications that might
cause such a drop in heart rate, then should inform the health care provider. Documentation is
important, but it is not the priority action. The heart rate is not low enough for atropine or an
external pacemaker to be needed.
An emergency room nurse obtains the health history of a client. Which statement by the client
should alert the nurse to the occurrence of heart failure?
a. "I get short of breath when I climb stairs."
b. "I see halos floating around my head."
c. "I have trouble remembering things."
d. "I have lost weight over the past month." - Answer a. "I get short of breath when I climb
stairs."
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity
such as stair climbing. The other findings are not specific to early occurrence of heart failure.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which
statement by the client should alert the nurse to the presence of edema?
a. "I wake up to go to the bathroom at night."
b. "My shoes fit tighter by the end of the day."
c. "I seem to be feeling more anxious lately."
,Weight gain can result from fluid accumulation in the interstitial spaces. This is known as
edema. The nurse should note whether the client feels that his or her shoes or rings are tight,
and should observe, when present, an indentation around the leg where the socks end. The
other answers do not describe edema.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical
manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm - Answer c. Disorientation and confusion
In older adults, disorientation or confusion may be the major manifestation of myocardial
infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the
arm could also be related to the myocardial infarction. However, the nurse should be more
concerned about the new onset of disorientation or confusion caused by decreased perfusion.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The
nurse notes that the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as "left pedal pulse of +1/4." - Answer c. Assess the color and
temperature of the left leg.
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial
obstruction. The pulse may be faint because of edema. The left pulse should be compared with
the right, and pulses should be compared with previous assessments, especially before the
procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease
in circulation. Once all peripheral and vascular assessment data are acquired, the primary health
care provider should be notified. Simply documenting the findings is inappropriate. The leg
should be positioned below the level of the heart or dangling to increase blood flow to the
distal portion of the leg. Increasing intravenous fluids will not address the client's problem.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which
assessment finding requires immediate intervention?
a. Urinary output less than intake
, A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident.
A change in neurologic status needs to be acted on immediately. Discomfort and bruising are
expected at the site. If intake decreases, a client can become dehydrated because of dye
excretion. The second intervention would be to increase the client's fluid status. Neurologic
changes would take priority.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment
should the nurse complete prior to this procedure?
a. Client's level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents - Answer d. Allergies to iodine-based agents
Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-
containing preparations, such as seafood or local anesthetics. The contrast medium used during
the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high
priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac
status.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The
client's health history includes a previous myocardial infarction and pacemaker implantation.
Which action should the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI. - Answer b. Notify the
health care provider before scheduling the MRI.
The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health
care provider and report that the client has a pacemaker so the provider can order other
diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased
fluids.
A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary
artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
