NUR 213 TEST #2 QUESTION WITH COMPLETE
SOLUTIONS LATEST 2025.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a
significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours - Answer
c. Poor peripheral pulses and cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be
reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen
saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is
normal.
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm
as shown below:
What action by the nurse is most important?
a. Assess the client's blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. - Answer
a. Assess the client's blood pressure and level of consciousness.
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the
client's hemodynamic status, including vital signs and level of consciousness. The client may or may
not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication
of this in the question.
,A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on
the client's sheets. What action should the nurse perform first?
a. Assess the insertion site.
b. Change the client's sheets.
c. Put on a pair of gloves.
d. Assess blood pressure. - Answer
c. Put on a pair of gloves.
For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The
other actions are appropriate as well, but first the nurse must don a pair of gloves.
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does
the nurse implement for this client?
a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends.
b. Ensure the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler's position. - Answer
b. Ensure the balloon does not remain wedged.
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should
ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and
assessing trends is an important nursing action related to hemodynamic monitoring, but is not
specifically related to safety. The client does not have to be NPO while undergoing hemodynamic
monitoring. Positioning may or may not affect readings.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes
the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped
from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
,d. Medicate the client for pain. - Answer
b. Assess the client for bleeding.
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the
insertion site. Since these vital signs are out of the normal range, are a change, and are consistent
with blood loss, the nurse should assess the client for any bleeding associated with the arterial
line. The nurse should document the findings after a full assessment. The client may or may not
need pain medication and rest; the nurse first needs to rule out any emergent bleeding.
A client has presented to the emergency department with an acute myocardial infarction (MI).
What action by the nurse is best to meet The Joint Commission's Core Measures outcomes?
a. Obtain an electrocardiogram (ECG) now and in the morning.
b. Give the client an aspirin.
c. Notify the Rapid Response Team.
d. Prepare to administer thrombolytics. - Answer
b. Give the client an aspirin.
The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a
client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid
ECG is vital, but getting another one in the morning is not part of the Core Measures set. The
Rapid Response Team is not needed if an emergency department provider is available.
Thrombolytics may or may not be needed.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea
and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider. - Answer
c. Maintain airway patency.
Airway always is the priority. The other actions are important in this situation as well, but the nurse
should stay with the client and ensure the airway remains patent (especially if vomiting occurs)
, while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG
done. Aspirin will probably be administered, depending on the provider's prescription and the
client's current medications.
A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic
comfort measures does the nurse include when caring for this client? (Select all that apply.)
a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing. - Answer
B,D,E
Nonpharmacologic comfort measures can include positioning, complementary therapies, and
splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort
measures.
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping
well since moving into the guest bedroom. What response by the nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
c. "Sleep near your spouse in case of emergency."
d. "Why would you move into the guest room?" - Answer
a. "Do you have any concerns about sexuality?"
Concerns about resuming sexual activity are common after cardiac events. The nurse should gently
inquire if this is the issue. While it is good that the client is sleeping well, the nurse should
investigate the reason for the move. The other two responses are likely to cause the client to be
defensive.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The
nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88
SOLUTIONS LATEST 2025.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a
significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours - Answer
c. Poor peripheral pulses and cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be
reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen
saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is
normal.
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm
as shown below:
What action by the nurse is most important?
a. Assess the client's blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. - Answer
a. Assess the client's blood pressure and level of consciousness.
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the
client's hemodynamic status, including vital signs and level of consciousness. The client may or may
not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication
of this in the question.
,A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on
the client's sheets. What action should the nurse perform first?
a. Assess the insertion site.
b. Change the client's sheets.
c. Put on a pair of gloves.
d. Assess blood pressure. - Answer
c. Put on a pair of gloves.
For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The
other actions are appropriate as well, but first the nurse must don a pair of gloves.
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does
the nurse implement for this client?
a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends.
b. Ensure the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler's position. - Answer
b. Ensure the balloon does not remain wedged.
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should
ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and
assessing trends is an important nursing action related to hemodynamic monitoring, but is not
specifically related to safety. The client does not have to be NPO while undergoing hemodynamic
monitoring. Positioning may or may not affect readings.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes
the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped
from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
,d. Medicate the client for pain. - Answer
b. Assess the client for bleeding.
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the
insertion site. Since these vital signs are out of the normal range, are a change, and are consistent
with blood loss, the nurse should assess the client for any bleeding associated with the arterial
line. The nurse should document the findings after a full assessment. The client may or may not
need pain medication and rest; the nurse first needs to rule out any emergent bleeding.
A client has presented to the emergency department with an acute myocardial infarction (MI).
What action by the nurse is best to meet The Joint Commission's Core Measures outcomes?
a. Obtain an electrocardiogram (ECG) now and in the morning.
b. Give the client an aspirin.
c. Notify the Rapid Response Team.
d. Prepare to administer thrombolytics. - Answer
b. Give the client an aspirin.
The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a
client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid
ECG is vital, but getting another one in the morning is not part of the Core Measures set. The
Rapid Response Team is not needed if an emergency department provider is available.
Thrombolytics may or may not be needed.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea
and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider. - Answer
c. Maintain airway patency.
Airway always is the priority. The other actions are important in this situation as well, but the nurse
should stay with the client and ensure the airway remains patent (especially if vomiting occurs)
, while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG
done. Aspirin will probably be administered, depending on the provider's prescription and the
client's current medications.
A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic
comfort measures does the nurse include when caring for this client? (Select all that apply.)
a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing. - Answer
B,D,E
Nonpharmacologic comfort measures can include positioning, complementary therapies, and
splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort
measures.
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping
well since moving into the guest bedroom. What response by the nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
c. "Sleep near your spouse in case of emergency."
d. "Why would you move into the guest room?" - Answer
a. "Do you have any concerns about sexuality?"
Concerns about resuming sexual activity are common after cardiac events. The nurse should gently
inquire if this is the issue. While it is good that the client is sleeping well, the nurse should
investigate the reason for the move. The other two responses are likely to cause the client to be
defensive.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The
nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88
