with Correct Answers 2025-2026
Updated.
2
The nurse should assess the client's blood pressure. - Answer A 24-week-gravid client is
being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days."
Which of the following is the most appropriate action for the nurse to perform next?
1. Inquire whether or not the client has allergies.
2. Take the woman's blood pressure.
3. Assess the woman's fundal height.
4. Ask the woman about stressors at work.
1
This primigravid client—age 44 and with a history of diabetes—is very high risk for
preeclampsia. - Answer Which of the following clients is at highest risk for developing a
hypertensive illness of pregnancy?
1. G1 P0000, age 44 with history of diabetes mellitus. 2. G2 P0101, age 27 with history of
rheumatic fever.
3. G3 P1102, age 25 with history of scoliosis.
4. G3 P1011, age 20 with history of celiac disease.
4
The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does
not require judgment. - Answer The nurse and an unlicensed assistive personnel (UAP) are
caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to
delegate to the UAP?
1. Assist the client to go down to the smoking area for a cigarette.
2. Transport the client to the intensive care unit via a stretcher.
3. Provide the client going home discharge-teaching instructions.
4. Help position the client who is having a portable x-ray done.
3
,morning.
2. The client who is having frequent incontinent liquid bowel movements and
vomiting.
3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood
pressure of 94/62.
4. The client who is complaining of chest pain with inspiration and a nonproductive
cough.
3
Troponin is the enzyme that elevates within 1 to 2 hours. - Answer Which cardiac enzyme
would the nurse expect to elevate first in a client diagnosed with a myocardial infarction?
1. Creatine kinase (CK-MB).
2. Lactate dehydrogenase (LDH).
3. Troponin.
4. White blood cells (WBCs).
2
Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood
from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin. - Answer
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse
suspect that the client is experiencing a myocardial infarction?
1. Midepigastric pain and pyrosis.
2. Diaphoresis and cool clammy skin.
3. Intermittent claudication and pallor.
4. Jugular vein distention and dependent edema.
3
Stopping all activity will decrease the need of the myocardium for oxygen and may help
decrease the chest pain. - Answer The client diagnosed with rule-out myocardial infarction is
experiencing chest pain while walking to the bathroom. Which action should the nurse
implement first?
1. Administer sublingual nitroglycerin.
2. Obtain a STAT electrocardiogram.
, Aspirin is an antiplatelet medication and should be administered orally. Oxygen will help
decrease myocardial ischemia, thereby decreasing pain. - Answer The nurse is caring for a
client diagnosed with a myocardial infarction who is experiencing chest pain. Which
interventions should the nurse implement? Select all that apply.
1. Administer morphine intramuscularly.
2. Administer an aspirin orally.
3. Apply oxygen via a nasal cannula.
4. Place the client in a supine position.
5. Administer nitroglycerin subcutaneously.
3
Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the
hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive
exercise, diet teaching, and classes on modifying risk factors. - Answer The client who has
had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral
would be most appropriate for the client?
1. Social worker.
2. Physical therapy.
3. Cardiac rehabilitation.
4. Occupational therapy.
2
The nurse must always assess the client to determine if the chest pain that is occurring is
expected postoperatively or if it is a complication of the surgery. - Answer The client is one
(1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which
intervention should the nurse implement first?
1. Medicate the client with intravenous morphine.
2. Assess the client's chest dressing and vital signs.
3. Encourage the client to turn from side to side.
4. Check the client's telemetry monitor.
3
Any neurovascular assessment data that are abnormal require intervention by the nurse;
numbness may indicate decreased blood supply to the right foot. - Answer The client
diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous