SECTION 1: CARDIOVASCULAR DISORDERS
QUESTION 1
A patient presents with pallor, decreased mean arterial pressure (MAP), tachycardia,
decreased urinary output, increased respiratory rate, hypotension, decreased pulse
pressure, and cold clammy skin. What is this patient most likely experiencing?
A) Myocardial infarction
B) Hemorrhage
C) Hypertensive crisis
D) Heart failure exacerbation
ANSWER: B
RATIONALE: These are classic signs and symptoms of hemorrhage, indicating
hypovolemic shock. The body compensates with tachycardia and increased respiratory
rate, while decreased perfusion leads to pallor, cool skin, and decreased urine output .
QUESTION 2
A nurse is assessing a client with acute decompensated heart failure (ADHF). Which
finding is most concerning?
A) +2 pitting edema in lower extremities
B) Jugular venous distension (JVD) at 45 degrees
C) Paroxysmal nocturnal dyspnea (PND)
D) Crackles audible to the midscapular region
ANSWER: D
RATIONALE: Crackles that extend to the midscapular region indicate that pulmonary
edema is severe and widespread, signifying imminent respiratory compromise. While
peripheral edema, JVD, and PND are important signs of fluid overload, they are not as
immediately life-threatening as extensive pulmonary edema .
QUESTION 3
A client with infective endocarditis develops sudden left-sided weakness and slurred
speech. What is the priority action?
A) Administer aspirin 325 mg PO
B) Obtain a STAT CT scan of the head
C) Check blood glucose level
D) Reorient the client to person, place, time
, ANSWER: B
RATIONALE: The client is likely experiencing an embolic stroke from a vegetation
fragment on the heart valve. A STAT CT scan is required to rule out hemorrhage before
any thrombolytics or anticoagulation can be considered .
QUESTION 4
Which of the following is a classic symptom of left-sided heart failure?
A) Peripheral edema
B) Ascites
C) Dyspnea and crackles
D) Jugular venous distension
ANSWER: C
RATIONALE: Left-sided heart failure results in pulmonary symptoms including dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, and crackles due to fluid backing up into the
lungs. Right-sided heart failure presents with peripheral symptoms such as edema,
ascites, and JVD .
QUESTION 5
A client on digoxin therapy reports nausea, vomiting, and visual disturbances. What
should the nurse suspect?
A) Therapeutic drug level
B) Digoxin toxicity
C) Allergic reaction
D) Medication noncompliance
ANSWER: B
RATIONALE: Nausea, vomiting, anorexia, and visual disturbances (yellow-green halos)
are classic signs of digoxin toxicity. The nurse should assess serum digoxin levels and
notify the healthcare provider .
QUESTION 6
A client with atrial fibrillation is prescribed warfarin. Which laboratory value should the
nurse monitor to evaluate therapeutic effectiveness?
A) PT/INR
B) aPTT
C) Platelet count
D) Hemoglobin
QUESTION 1
A patient presents with pallor, decreased mean arterial pressure (MAP), tachycardia,
decreased urinary output, increased respiratory rate, hypotension, decreased pulse
pressure, and cold clammy skin. What is this patient most likely experiencing?
A) Myocardial infarction
B) Hemorrhage
C) Hypertensive crisis
D) Heart failure exacerbation
ANSWER: B
RATIONALE: These are classic signs and symptoms of hemorrhage, indicating
hypovolemic shock. The body compensates with tachycardia and increased respiratory
rate, while decreased perfusion leads to pallor, cool skin, and decreased urine output .
QUESTION 2
A nurse is assessing a client with acute decompensated heart failure (ADHF). Which
finding is most concerning?
A) +2 pitting edema in lower extremities
B) Jugular venous distension (JVD) at 45 degrees
C) Paroxysmal nocturnal dyspnea (PND)
D) Crackles audible to the midscapular region
ANSWER: D
RATIONALE: Crackles that extend to the midscapular region indicate that pulmonary
edema is severe and widespread, signifying imminent respiratory compromise. While
peripheral edema, JVD, and PND are important signs of fluid overload, they are not as
immediately life-threatening as extensive pulmonary edema .
QUESTION 3
A client with infective endocarditis develops sudden left-sided weakness and slurred
speech. What is the priority action?
A) Administer aspirin 325 mg PO
B) Obtain a STAT CT scan of the head
C) Check blood glucose level
D) Reorient the client to person, place, time
, ANSWER: B
RATIONALE: The client is likely experiencing an embolic stroke from a vegetation
fragment on the heart valve. A STAT CT scan is required to rule out hemorrhage before
any thrombolytics or anticoagulation can be considered .
QUESTION 4
Which of the following is a classic symptom of left-sided heart failure?
A) Peripheral edema
B) Ascites
C) Dyspnea and crackles
D) Jugular venous distension
ANSWER: C
RATIONALE: Left-sided heart failure results in pulmonary symptoms including dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, and crackles due to fluid backing up into the
lungs. Right-sided heart failure presents with peripheral symptoms such as edema,
ascites, and JVD .
QUESTION 5
A client on digoxin therapy reports nausea, vomiting, and visual disturbances. What
should the nurse suspect?
A) Therapeutic drug level
B) Digoxin toxicity
C) Allergic reaction
D) Medication noncompliance
ANSWER: B
RATIONALE: Nausea, vomiting, anorexia, and visual disturbances (yellow-green halos)
are classic signs of digoxin toxicity. The nurse should assess serum digoxin levels and
notify the healthcare provider .
QUESTION 6
A client with atrial fibrillation is prescribed warfarin. Which laboratory value should the
nurse monitor to evaluate therapeutic effectiveness?
A) PT/INR
B) aPTT
C) Platelet count
D) Hemoglobin
