And Correct answers 2025\2026
d - correct answerA nurse is reviewing the medical record of a client who is receiving heparin therapy for
treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client's
aPTT is 96 seconds?
a. Increase the heparin infusion flow rate by 2 mL/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time
d. stop the heparin infusion
a - correct answerA nurse is providing teaching for a client who is 2 days post-op following a heart
trcorrect answerplant. Which of the following statements should the nurse include in the teaching?
a. "you may no longer be able to feel chest pain.
"b. "your level of activity tolerance will not change."
c. "after 6 months, you will no longer need to restrict your sodium intake."
d. "you will be able to stop taking immunosuppressants after 12 months."
a - correct answerA nurse is assess a client in the emergency room who has a bradydysrhythmia. Which
of the following findings should the nurse expect?
A. confusion
B. friction rub
C. hypertension
D. dry skin
d - correct answerA nurse in the emergency department is caring for a client who had an anterior MI.
The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize
that which of the following interventions is contraindicated?
A. administering IV morphine sulfate
B. administering oxygen at 2 :/min via nasal cannula
,C. helping the client to the bedside commode
D. assisting with thrombolytic therapy
D - correct answerA nurse is caring for a client who has endocarditis. Which of the following findings
should the nurse recognize as a potential complication?
A. ventricular depolarization
B. Guillain-Barre syndrome
C. myelodysplastic syndrome
D. Valvular disease
C - correct answerA nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The
nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the
nurse take first?
A. obtain blood samples for laboratory testing
B. Tell the client to report vision changes
C. Place the head of the bed at 45 degrees
D. initiate an IV
a - correct answera nurse is caring for a client who has HF and is experiencing AF. The nurse should plan
to monitor for and report which of the following findings to the provider immediately?
a. slurred speech
b. irregular pulse
c. dependent edema
d. persistent fatigue
b - correct answerA nurse is assessing a client who has left-sided HF. Which of the following
manifestations should the nurse expect to find?
a. inc abdominal girth
b. weak peripheral pulses
c. jugular vein distention
,d. dependent edema
b - correct answera nurse is caring for a client who is being treated for HF and has prescriptions for
digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse
effect of these medications?
a. SOB
b. lightheadedness
c. dry cough
d. metallic taste
c - correct answera nurse is monitoring a client following coronary artery bypass graft surgery. Which of
the following findings can indicate cardiac tamponade?
a. sternal instability
b. inc WBC count
c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration
d. sinus rhythm with occasional premature atrial contraction and HR 88/min
d - correct answerA nurse is preparing a client for coronary angiography. The nurse should report which
of the following findings to the provider prior to the procedure?
a. hemoglobin 14.4 g/dL
b. history of peripheral arterial disease
c. urine output 200 mL/4 hr
d. previous allergic reaction to shellfish
a - correct answerA nurse is caring for a client following insertion of a permanent pacemaker. Which of
the following client statements indicates a potential complication of the insertion procedure?
a. "I can't get rid of these hiccups."
b. "I feel dizzy when i stand."
c. "My incision site stings."
d. "I have a headache."
, b - correct answerA nurse is providing discharge teaching for a client who has a prescription for the
trcorrect answerdermal nitroglycerin patch. Which of the following instructions should the nurse include
in the teaching?
a. apply the new patch to the same site as the previous patch
b. place the patch on an area of skin away from skin folds and joints
c. keep the patch on 24 hr per day
d. replace the patch at the onset of angina
c - correct answerA nurse is caring for a client in the first hour following an aortic aneurysm repair.
Which of the following findings can indicate shock and should be reported to the provider?
a. serosanguinous drainage on dressing
b. severe pain with coughing
c. urine output of 20 mL/hr
d. increase in temp from 36.C (98.2F)- 37.5C (99.5F)
d - correct answerA nurse caring for a client following an abdominal aortic aneurysm resection. Which of
the following is the priority assessment for this client?
a. neck vein distention
b. bowel sounds
c. peripheral edema
d. urine output
b - correct answerA nurse is watching a client's ECG monitor and notes that the client's rhythm has
changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR
of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the
following interventions?
a. delivery of precordial thump
b. vagal stimulation
c. administration of atropine IV
d. defibrillation