MYOCARDIAL INFARCTION AND HEART FAILURE

Text Mode – Text version of the exam

1) The nurse should visit which of the following clients first?

A. The client with diabetes with a blood glucose of 95mg/dL

B. The client with hypertension being maintained on Lisinopril
C. The client with chest pain and a history of angina
D. The client with Raynaud’s disease
2) A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed
rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which
of the following conditions is the most likely cause of her symptoms?

A. Myocardial infarction due to a history of atherosclerosis.

B. Pulmonary embolism due to deep vein thrombosis (DVT).
C. Anxiety attack due to worries about her baby’s health.
D. Congestive heart failure due to fluid overload.
3) What is the primary reason for administering morphine to a client with myocardial infarction?

A. To sedate the client

B. To decrease the client’s pain
C. To decrease the client’s anxiety
D. To decrease oxygen demand on the client’s heart
4) A patient arrives in the emergency department with symptoms of myocardial infarction,
progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the
patient to exhibit with cardiogenic shock?

A. Hypertension.
B. Bradycardia.
C. Bounding pulse.
D. Confusion.
5) In order to be effective, Percutaneous Transluminal Coronary Angioplasty (PTCA) must be
performed within what time frame, beginning with arrival at the emergency department after
diagnosis of myocardial infarction?

A. 60 minutes
B. 30 minutes
C. 9 days
D. 6-12 months
6) Helen, a nurse from the maternity unit is floated to the critical care unit because of staff
shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client
with:

A. Dopamine drip IV with vital signs monitored every 5 minutes

B. a myocardial infarction that is free from pain and dysrhythmias
C. a tracheotomy of 24 hours in some respiratory distress
D. a pacemaker inserted this morning with intermittent capture
7) A female client is brought by ambulance to the hospital emergency room after taking an
overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the
following?

A. Epilepsy
B. Myocardial Infarction
C. Renal failure
D. Respiratory failure
8) Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the
emergency department following onset of symptoms of myocardial infarction. Which of the
following is a contraindication for treatment with t-PA?

A. Worsening chest pain that began earlier in the evening.

B. History of cerebral hemorrhage.
C. History of prior myocardial infarction.
D. Hypertension.
9) A patient admitted to the hospital with myocardial infarction develops severe pulmonary
edema. Which of the following symptoms should the nurse expect the patient to exhibit?

A. Slow, deep respirations.

B. Stridor.
C. Bradycardia.
D. Air hunger.
10) A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders
that occurs at rest, with high body temperature, weak with generalized sweating and with
decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most
accurate explanation for one of these presenting adaptations is:

A. Catecholamines released at the site of the infarction causes intermittent localized pain.
B. Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
C. Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
D. Inflammation in the myocardium causes a rise in the systemic body temperature.
11) Which of the following is the most common symptom of myocardial infarction?

A. Chest pain
B. Dyspnea
C. Edema
D. Palpitations
12) Nursing measures for the client who has had an MI include helping the client to avoid activity
that results in Valsalva’s maneuver. Valsalva’s maneuver may cause cardiac dysrhythmias,
increased venous pressure, increased intrathoracic pressure and thrombi dislodgement. Which
of the following actions would help prevent Valsalva’s maneuver? Have the client:

A. Assume a side-lying position

B. Clench her teeth while moving in bed
C. Drink fluids through a straw
D. Avoid holding her breath during activity
13) The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks
the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response
by the nurse to this question?
 A. “You need to regain your strength before attempting such exertion.”
B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
C. “Have a glass of wine to relax you, then you can try to have sex.”
D. “If you can maintain an active walking program, you will have less risk.”
14) Following myocardial infarction, a hospitalized patient is encouraged to practice frequent
leg exercises and ambulate in the hallway as directed by his physician. Which of the following
choices reflects the purpose of exercise for this patient?

A. Increases fitness and prevents future heart attacks.

B. Prevents bedsores.
C. Prevents DVT (deep vein thrombosis).
D. Prevent constipations.
15) Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial
infarction. Which nursing intervention should appear on this client’s plan of care?

A. Perform activities of daily living for the client to decease frustration.

B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as possible.
16) Which statement best describes the difference between the pain of angina and the pain of
myocardial infarction?

A. Pain associated with angina is relieved by rest.

B. Pain associated with myocardial infarction is always more severe.
C. Pain associated with angina is confined to the chest area.
D. Pain associated with myocardial infarction is referred to the left arm.
17) Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking
morphine. The nurse explains that morphine:

A. Decrease anxiety and restlessness

B. Prevents shock and relieves pain
C. Dilates coronary blood vessels
D. Helps prevent fibrillation of the heart
18) An early finding in the EKG of a client with an infarcted mycardium would be:

A. Disappearance of Q waves
B. Elevated ST segments
C. Absence of P wave
D. Flattened T waves
19) A nurse caring for several patients on the cardiac unit is told that one is scheduled for
implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is
most likely to have this procedure?

A. A patient admitted for myocardial infarction without cardiac muscle damage.

B. A post-operative coronary bypass patient, recovering on schedule.
C. A patient with a history of ventricular tachycardia and syncopal episodes.
D. A patient with a history of atrial tachycardia and fatigue.
20) Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The
nurse monitors him for other adaptations related to the pyrexia, including:

A. Shortness of breath
 B. Chest pain
C. Elevated blood pressure
D. Increased pulse rate
21) Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER with a
typical description of pain associated with an MI, and is now cold and clammy, pale and
dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has
not been started, and he is not on the monitor. He is frightened. During the first three days that
Mr. Duffy is in the CCU, a number of diagnostic blood tests are obtained. Which of the following
patterns of cardiac enzyme elevation are most common following an MI?

A. SGOT, CK, and LDH are all elevated immediately.

B. SGOT rises 4-6 hours after infarction with CK and LDH rising slowly 24 hours later.
C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the LDH
(peaks 3-4 days).
D. CK peaks first and remains elevated for 1 to 2 weeks.
22) To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction,
the nurse would

A. Assist the client to use the bedside commode

B. Administer stool softeners every day as ordered
C. Administer antidysrhythmics prn as ordered
D. Maintain the client on strict bed rest
23) A male client with chronic obstructive pulmonary disease (COPD) is recovering from a
myocardial infarction. Because the client is extremely weak and can’t produce an effective
cough, the nurse should monitor closely for:

A. Pleural effusion.
B. Pulmonary edema.
C. Atelectasis.
D. Oxygen toxicity.
24) A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What
should the nurse do first?

A. Allow the client to view his chart

B. Contact the supervisor and physician for approval
C. Ask the client if he has concerns about his care
D. Tell the client that he isn’t permitted to view his chart.
25) A client with a history of an anterior wall myocardial infarction is being transferred from the
coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU
nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal
range.” The CSU nurse should be especially observant for:

A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles
26) Which patient’s nursing care would be most appropriate for the charge nurse to assign to
the LPN, under the supervision of the RN team leader?

A. A 51-year-old patient with bilateral adrenalectomy just returned from the post-anesthesia
care unit
 B. An 83-year-old patient with type 2 diabetes and chronic obstructive pulmonary disease
C. A 38-year-old patient with myocardial infarction who is preparing for discharge
D. A 72-year-old patient admitted from long-term care with mental status changes
27) During the second day of hospitalization of the client after a Myocardial Infarction. Which of
the following is an expected outcome?

A. Able to perform self-care activities without pain

B. Severe chest pain
C. Can recognize the risk factors of Myocardial Infarction
D. Can Participate in cardiac rehabilitation walking program
28) The client with an acute myocardial infarction is hospitalized for almost one week. The client
experiences nausea and loss of appetite. The nurse caring for the client recognizes that these
symptoms may indicate the:

A. Adverse effects of spironolactone (Aldactone)

B. Adverse effects of digoxin (Lanoxin)
C. Therapeutic effects of propranolol (Indiral)
D. Therapeutic effects of furosemide (Lasix)
29) Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from
myocardial infarction. Which of the following is the most essential nursing action?

A. Monitoring urine output frequently

B. Monitoring blood pressure every 4 hours
C. Obtaining serum potassium levels daily
D. Obtaining infusion pump for the medication
30) On the evening shift, the triage nurse evaluates several clients who were brought to the
emergency department. Which in the following clients should receive highest priority?

A. an elderly woman complaining of a loss of appetite and fatigue for the past week
B. A football player limping and complaining of pain and swelling in the right ankle
C. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
D. A mother with a 5-year-old boy who says her son has been complaining of nausea and
vomited once since noon
31) Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?

A. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
D. A 63 year-old post operative’s abdominal hysterectomy client of three days whose
incisional dressing is saturated with serosanguinous fluid.
32) After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is
teaching the client about the diet, which meal plan would be the most appropriate to suggest?

A. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
33) The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of
the following:
 A. Pulmonary embolism
B. Cardiac arrest
C. Thrombus formation
D. Myocardial infarction
34) Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse
about issues related to his hospital stay. The best initial nursing response would be to:

A. Allow him to release his feelings and then leave him alone to allow him to regain his
composure
B. Refocus the conversation on his fears, frustrations and anger about his condition
C. Explain how his being upset dangerously disturbs his need for rest
D. Attempt to explain the purpose of different hospital routines
35) Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the
side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

A. Call for help and note the time.

B. Clear the airway
C. Give two sharp thumps to the precordium, and check the pulse.
D. Administer two quick blows.
36) Which of the following actions is the first priority of care for a client exhibiting signs and
symptoms of coronary artery disease?

A. Decrease anxiety
B. Enhance myocardial oxygenation
C. Administer sublingual nitroglycerin
D. Educate the client about his symptoms
37) Medical treatment of coronary artery disease includes which of the following procedures?

A. Cardiac catherization
B. Coronary artery bypass surgery
C. Oral medication therapy
D. Percutaneous transluminal coronary angioplasty
38) Which of the following is the most common symptom of myocardial infarction (MI)?

A. Chest pain
B. Dyspnea
C. Edema
D. Palpitations
39) Which of the following symptoms is the most likely origin of pain the client described as
knifelike chest pain that increases in intensity with inspiration?

A. Cardiac
B. Gastrointestinal
C. Musculoskeletal
D. Pulmonary
40) Which of the following blood tests is most indicative of cardiac damage?

A. Lactate dehydrogenase
B. Complete blood count (CBC)
C. Troponin I
D. Creatine kinase (CK)
41) What is the primary reason for administering morphine to a client with an MI?

A. To sedate the client

B. To decrease the client’s pain
C. To decrease the client’s anxiety
D. To decrease oxygen demand on the client’s heart
42) Which of the following conditions is most commonly responsible for myocardial
infarction?

A. Aneurysm
B. Heart failure
C. Coronary artery thrombosis
D. Renal failure
43) Which of the following complications is indicated by a third heart sound (S3)?
A. Ventricular dilation
B. Systemic hypertension
C. Aortic valve malfunction
D. Increased atrial contractions
44) After an anterior wall myocardial infarction, which of the following problems is indicated
by auscultation of crackles in the lungs?

A. Left-sided heart failure

B. Pulmonic valve malfunction
C. Right-sided heart failure
D. Tricupsid valve malfunction
45) What is the first intervention for a client experiencing MI?

A. Administer morphine
B. Administer oxygen
C. Administer sublingual nitroglycerin
D. Obtain an ECG
46) Which of the following classes of medications protects the ischemic myocardium by
blocking catecholamines and sympathetic nerve stimulation?

A. Beta-adrenergic blockers
B. Calcium channel blockers
C. Narcotics
D. Nitrates
47) What is the most common complication of an MI?

A. Cardiogenic shock
B. Heart failure
C. arrhythmias
D. Pericarditis
48) With which of the following disorders is jugular vein distention most prominent?

A. Abdominal aortic aneurysm

B. Heart failure
C. MI
D. Pneumothorax
49) Toxicity from which of the following medications may cause a client to see a green-yellow
halo around lights?

A. Digoxin
B. Furosemide (Lasix)
C. Metoprolol (Lopressor)
D. Enalapril (Vasotec)
50) Which of the following symptoms is most commonly associated with left-sided heart failure?

A. Crackles
B. Arrhythmias
C. Hepatic engorgement
D. Hypotension
51) In which of the following disorders would the nurse expect to assess sacral edema in a
bedridden client?

A. Diabetes
B. Pulmonary emboli
C. Renal failure
D. Right-sided heart failure
52) Which of the following symptoms might a client with right-sided heart failure exhibit?

A. Adequate urine output

B. Polyuria
C. Oliguria
D. Polydipsia
53) Which of the following classes of medications maximizes cardiac performance in clients
with heart failure by increasing ventricular contractibility?

A. Beta-adrenergic blockers
B. Calcium channel blockers
C. Diuretics
D. Inotropic agents
54) Stimulation of the sympathetic nervous system produces which of the following responses?

A. Bradycardia
B. Tachycardia
C. Hypotension
D. Decreased myocardial contractility
55) Which of the following conditions is most closely associated with weight gain, nausea, and
a decrease in urine output?

A. Angina pectoris
B. Cardiomyopathy
C. Left-sided heart failure
D. Right-sided heart failure
56) Which of the following heart muscle diseases is unrelated to other cardiovascular disease?

A. Cardiomyopathy
B. Coronary artery disease
C. Myocardial infarction
 D. Pericardial effusion
57) Which of the following types of cardiomyopathy can be associated with childbirth?

A. Dilated
B. Hypertrophic
C. Myocarditis
D. Restrictive
58) Septal involvement occurs in which type of cardiomyopathy?

A. Congestive
B. Dilated
C. Hypertrophic
D. Restrictive
59) Which of the following recurring conditions most commonly occurs in clients with
cardiomyopathy?

A. Heart failure
B. Diabetes
C. MI
D. Pericardial effusion
60) Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of
which of the following conditions?

A. Pericarditis
B. Hypertension
C. MI
D. Heart failure
61) In which of the following types of cardiomyopathy does cardiac output remain normal?

A. Dilated
B. Hypertrophic
C. Obliterative
D. Restrictive
62) Which of the following cardiac conditions does a fourth heart sound (S 4) indicate?
A. Dilated aorta
B. Normally functioning heart
C. Decreased myocardial contractility
D. Failure of the ventricle to eject all of the blood during systole
63) Which of the following classes of drugs is most widely used in the treatment of
cardiomyopathy?

A. Antihypertensives
B. Beta-adrenergic blockers
C. Calcium channel blockers
D. Nitrates
64) If medical treatments fail, which of the following invasive procedures is necessary for
treating cariomyopathy?

A. Cardiac catherization
B. Coronary artery bypass graft (CABG)
C. Heart transplantation
 D. Intra-aortic balloon pump (IABP)
65) Which of the following conditions is associated with a predictable level of pain that occurs
as a result of physical or emotional stress?

A. Anxiety
B. Stable angina
C. Unstable angina
D. Variant angina
66) Which of the following types of angina is most closely related with an impending MI?

A. Angina decubitus
B. Chronic stable angina
C. Noctural angina
D. Unstable angina
67) Which of the following conditions is the predominant cause of angina?

A. Increased preload
B. Decreased afterload
C. Coronary artery spasm
D. Inadequate oxygen supply to the myocardium
68) Which of the following tests is used most often to diagnose angina?

A. Chest x-ray
B. Echocardiogram
C. Cardiac catherization
D. 12-lead electrocardiogram (ECG)
69) Which of the following results is the primary treatment goal for angina?

A. Reversal of ischemia
B. Reversal of infarction
C. Reduction of stress and anxiety
D. Reduction of associated risk factors
70) Which of the following interventions should be the first priority when treating a client
experiencing chest pain while walking?

A. Sit the client down

B. Get the client back to bed
C. Obtain an ECG
D. Administer sublingual nitroglycerin
71) Myocardial oxygen consumption increases as which of the following parameters increase?

A. Preload, afterload, and cerebral blood flow

B. Preload, afterload, and renal blood flow
C. Preload, afterload, contractility, and heart rate.
D. Preload, afterload, cerebral blood flow, and heart rate.
72) Which of the following positions would best aid breathing for a client with acute pulmonary
edema?

A. Lying flat in bed

B. Left side-lying
C. In high Fowler’s position
 D. In semi-Fowler’s position
73) Which of the following blood gas abnormalities is initially most suggestive of pulmonary
edema?

A. Anoxia
B. Hypercapnia
C. Hyperoxygenation
D. Hypocapnia
74) Which of the following is a compensatory response to decreased cardiac output?

A. Decreased BP
B. Alteration in LOC
C. Decreased BP and diuresis
D. Increased BP and fluid retention
75) Which of the following actions is the appropriate initial response to a client coughing up
pink, frothy sputum?

A. Call for help

B. Call the physician
C. Start an I.V. line
D. Suction the client
76) Which of the following terms describes the force against which the ventricle must expel
blood?

A. Afterload
B. Cardiac output
C. Overload
D. Preload
77) Acute pulmonary edema caused by heart failure is usually a result of damage to which of
the following areas of the heart?

A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle
78) An 18-year-old client who recently had an URI is admitted with suspected rheumatic fever.
Which assessment findings confirm this diagnosis?

A. Erythema marginatum, subcutaneous nodules, and fever

B. Tachycardia, finger clubbing, and a load S3
C. Dyspnea, cough, and palpitations
D. Dyspnea, fatigue, and synocope
79) A client admitted with angina compains of severe chest pain and suddenly becomes
unresponsive. After establishing unresponsiveness, which of the following actions should the
nurse take first?

A. Activate the resuscitation team

B. Open the client’s airway
C. Check for breathing
D. Check for signs of circulation
80) A 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During the
admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago because
he was feeling better. Which of the following nursing diagnoses takes priority for this client?

A. Anxiety
B. Ineffective tissue perfusion; cardiopulmonary
C. Acute pain
D. Ineffective therapeutic regimen management
81) A client comes into the E.R. with acute shortness of breath and a cough that produces pink,
frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122
BPM, and a respiratory rate of 38 breaths/minute. The client’s medical history included DM, HTN,
and heart failure. Which of the following disorders should the nurse suspect?

A. Pulmonary edema
B. Pneumothorax
C. Cardiac tamponade
D. Pulmonary embolus
82) The nurse coming on duty receives the report from the nurse going off duty. Which of the
following clients should the on-duty nurse assess first?

A. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a
respiratory rate of 21 breaths a minute.
B. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order.
C. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving
IV heparin.
D. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is
receiving IV diltiazem (Cardizem).
83) When developing a teaching plan for a client with endocarditis, which of the following
points is most essential for the nurse to include?

A. “Report fever, anorexia, and night sweats to the physician.”

B. “Take prophylactic antibiotics after dental work and invasive procedures.”
C. “Include potassium rich foods in your diet.”
D. “Monitor your pulse regularly.”
84) A nurse is conducting a health history with a client with a primary diagnosis of heart failure.
Which of the following disorders reported by the client is unlikely to play a role in exacerbating
the heart failure?

A. Recent URI
B. Nutritional anemia
C. Peptic ulcer disease
D. A-Fib
85) A nurse is preparing for the admission of a client with heart failure who is being sent directly
to the hospital from the physician’s office. The nurse would plan on having which of the following
medications readily available for use?

A. Diltiazem (Cardizem)
B. Digoxin (Lanoxin)
C. Propranolol (Inderal)
D. Metoprolol (Lopressor)
86) A nurse caring for a client in one room is told by another nurse that a second client has
developed severe pulmonary edema. On entering the 2nd client’s room, the nurse would expect
the client to be:
A. Slightly anxious
B. Mildly anxious
C. Moderately anxious
D. Extremely anxious
87) A client with pulmonary edema has been on diuretic therapy. The client has an order for
additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be
started on Digoxin (Lanoxin), a nurse checks the client’s most recent:

A. Digoxin level
B. Sodium level
C. Potassium level
D. Creatinine level
88) A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for 2
hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the subsequent hour
was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45 mg/dL and the serum
creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:

A. Hypovolemia
B. UTI
C. Glomerulonephritis
D. Acute renal failure
89) A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse
would plan to do which of the following to enable the client to best tolerate the ambulation?
A. Encourage the client to cough and deep breathe
B. Premedicate the client with an analgesic
C. Provide the client with a walker
D. Remove telemetry equipment because it weighs down the hospital gown.
90) A client’s electrocardiogram strip shows atrial and ventricular rates of 80 complexes per
minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse
interprets this rhythm is:

A. Normal sinus rhythm

B. Sinus bradycardia
C. Sinus tachycardia
D. Sinus dysrhythmia
91) A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is
most concerned with this dysrhythmia because:

A. It is uncomfortable for the client, giving a sense of impending doom.

B. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.
C. It is almost impossible to convert to a normal sinus rhythm.
D. It can develop into ventricular fibrillation at any time.
92) A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the
treatment of heart failure. The nurse would particularly assess the client for:

A. Thrombocytopenia and weight gain

B. Anorexia, nausea, and visual disturbances
C. Diarrhea and hypotension
 D. Fatigue and muscle twitching
93) A client with angina complains that the angina pain is prolonged and severe and occurs at
the same time each day, most often in the morning, On further assessment a nurse notes that
the pain occurs in the absence of precipitating factors. This type of anginal pain is best
described as:

A. Stable angina
B. Unstable angina
C. Variant angina
D. Nonanginal pain
94) The physician orders continuous intravenous nitroglycerin infusion for the client with MI.
Essential nursing actions include which of the following?

A. Obtaining an infusion pump for the medication

B. Monitoring BP q4h
C. Monitoring urine output hourly
D. Obtaining serum potassium levels daily
95) Aspirin is administered to the client experiencing an MI because of its:

A. Antipyrectic action
B. Antithrombotic action
C. Antiplatelet action
D. Analgesic action
96) Which of the following is an expected outcome for a client on the second day of
hospitalization after an MI?

A. Has severe chest pain

B. Can identify risks factors for MI
C. Agrees to participate in a cardiac rehabilitation walking program
D. Can perform personal self-care activities without pain
97) Which of the following reflects the principle on which a client’s diet will most likely be based
during the acute phase of MI?

A. Liquids as ordered
B. Small, easily digested meals
C. Three regular meals per day
D. NPO
98) An older, sedentary adult may not respond to emotional or physical stress as well as a
younger individual because of:

A. Left ventricular atrophy

B. Irregular heartbeats
C. peripheral vascular occlusion
D. Pacemaker placement
99) Which of the following nursing diagnoses would be appropriate for a client with heart
failure? Select all that apply.
A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
B. Activity intolerance related to increased cardiac output.
C. Decreased cardiac output related to structural and functional changes.
D. Impaired gas exchange related to decreased sympathetic nervous system activity.
100) Which of the following would be a priority nursing diagnosis for the client with heart failure
and pulmonary edema?

A. Risk for infection related to stasis of alveolar secretions

B. Impaired skin integrity related to pressure
C. Activity intolerance related to pump failure
D. Constipation related to immobility
101) Captopril may be administered to a client with HF because it acts as a:

A. Vasopressor
B. Volume expander
C. Vasodilator
D. Potassium-sparing diuretic
102) Furosemide is administered intravenously to a client with HF. How soon after administration
should the nurse begin to see evidence of the drugs desired effect?

A. 5 to 10 minutes
B. 30 to 60 minutes
C. 2 to 4 hours
D. 6 to 8 hours
103) Which of the following foods should the nurse teach a client with heart failure to avoid or
limit when following a 2-gram sodium diet?

A. Apples
B. Tomato juice
C. Whole wheat bread
D. Beef tenderloin
104) The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects:
A. Left atrial enlargement
B. Left ventricular enlargement
C. Right atrial enlargement
D. Right ventricular enlargement
Answers and Rationales

1. C. The client with chest pain and a history of angina . The client with chest pain should be
seen first because this could indicate a myocardial infarction. The client in answer A has a
blood glucose within normal limits. The client in answer B is maintained on blood pressure
medication. The client in answer D is in no distress.
2. B. Pulmonary embolism due to deep vein thrombosis (DVT). In a hospitalized patient on
prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest
pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of
clot formation in the deep veins of the legs. These clots can then break loose and travel to
the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as
is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety
disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness
of pulmonary embolism demands that it be considered first.
3. D. To decrease oxygen demand on the client’s heart . Morphine is administered because it
decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety
while causing sedation, but isn’t primarily given for those reasons.
4. D. Confusion. Cardiogenic shock severely impairs the pumping function of the heart
muscle, causing diminished blood flow to the organs of the body. This results in diminished
brain function and confusion, as well as hypotension, tachycardia, and weak pulse.
 Cardiogenic shock is a serious complication of myocardial infarction with a high mortality
rate.
5. A. 60 minutes . The sixty minute interval is known as “door to balloon time” for performance
of PTCA on a diagnosed MI patient.
6. B. a myocardial infarction that is free from pain and dysrhythmias. This client is the most
stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills
to care for this client.
7. D. Respiratory failure . Barbiturates are CNS depressants; the nurse would be especially alert
for the possibility of respiratory failure. Respiratory failure is the most likely cause of death
from barbiturate over dose.
8. B. History of cerebral hemorrhage. A history of cerebral hemorrhage is a contraindication to
tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking
the coronary artery and works best when administered within 6 hours of onset of symptoms.
Prior MI is not a contraindication to tPA. Patients receiving tPA should be observed for
changes in blood pressure, as tPA may cause hypotension.
9. D. Air hunger. Patients with pulmonary edema experience air hunger, anxiety, and
agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing
caused by laryngeal swelling or spasm and is not associated with pulmonary edema.
10. D. Inflammation in the myocardium causes a rise in the systemic body temperature.
. Temperature may increase within the first 24 hours and persist as long as a week.
11. A. Chest pain . The most common symptom of an MI is chest pain, resulting from deprivation
of oxygen to the heart. Dyspnea is the second most common symptom, related to an
increase in the metabolic needs of the body during an MI. Edema is a later sign of heart
failure, often seen after an MI. Palpitations may result from reduced cardiac output,
producing arrhythmias.
12. D. Avoid holding her breath during activity
13. B. “When you can climb 2 flights of stairs without problems, it is generally safe.” “When you
can climb 2 flights of stairs without problems, it is generally safe.” There is a risk of cardiac
rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form
about that time. Waiting until the client can tolerate climbing stairs is the usual advice given
by health care providers.
14. C. Prevents DVT (deep vein thrombosis). Exercise is important for all hospitalized patients to
prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents
hemostasis in the lower extremities. This exercise is not sufficiently vigorous to increase
physical fitness, nor is it intended to prevent bedsores or constipation.
15. C. Establish and maintain a routine. Establishing and maintaining a routine is essential to
decreasing extraneous stimuli. The client should participate in daily care as much as
possible. Attempting to reason with such clients isn’t successful, because they can’t
participate in abstract thinking.
16. A. Pain associated with angina is relieved by rest. Pain associated with angina is relieved by
rest. Answer B is incorrect because it is not a true statement. Answer Pain associated with
angina is confined to the chest area is incorrect because pain associated with angina can
be referred to the jaw, the left arm, and the back. Pain associated with myocardial
infarction is referred to the left arm is incorrect because pain from a myocardial infarction
can be referred to areas other than the left arm.
17. B. Prevents shock and relieves pain. Morphine is a central nervous system depressant used
to relieve the pain associated with myocardial infarction, it also decreases apprehension
and prevents cardiogenic shock.
18. B. Elevated ST segments . This is a typical early finding after a myocardial infarct because of
the altered contractility of the heart. The other choices are not typical of MI.
19. C. A patient with a history of ventricular tachycardia and syncopal episodes. . An
automatic internal cardioverter-defibrillator delivers an electric shock to the heart to
 terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in
a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A
patient with myocardial infarction that resolved with no permanent cardiac damage would
not be a candidate. A patient recovering well from coronary bypass would not need the
device. Atrial tachycardia is less serious and is treated conservatively with medication and
cardioversion as a last resort.
20. D. Increased pulse rate . Fever causes an increase in the body’s metabolism, which results in
an increase in oxygen consumption and demand. This need for oxygen increases the heart
rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness
of breath are not typically noted in fever.
21. C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the
LDH (peaks 3-4 days). Although the timing of initial elevation, peak elevation, and duration
of elevation vary with sources, current literature favors letter c.
22. B. Administer stool softeners every day as ordered . Administering stool softeners every day
will prevent straining on defecation which causes the Valsalva maneuver. If constipation
occurs then laxatives would be necessary to prevent straining. If straining on defecation
produced the valsalva maneuver and rhythm disturbances resulted then antidysrhythmics
would be appropriate.
23. C. Atelectasis. In a client with COPD, an ineffective cough impedes secretion removal. This,
in turn, causes mucus plugging, which leads to localized airway obstruction — a known
cause of atelectasis. An ineffective cough doesn’t cause pleural effusion (fluid
accumulation in the pleural space). Pulmonary edema usually results from left-sided heart
failure, not an ineffective cough. Although many noncardiac conditions may cause
pulmonary edema, an ineffective cough isn’t one of them. Oxygen toxicity results from
prolonged administration of high oxygen concentrations, not an ineffective cough.
24. C. Ask the client if he has concerns about his care
25. D. pulmonary crackles . High pulmonary artery wedge pressures are diagnostic for left-sided
heart failure. With leftsided heart failure, pulmonary edema can develop causing
pulmonary crackles. In leftsided heart failure, hypotension may result and urine output will
decline. Dry mucous membranes aren’t directly associated with elevated pulmonary artery
wedge pressures.
26. B. An 83-year-old patient with type 2 diabetes and chronic obstructive pulmonary disease
. The 83-year-old patient has no complicating factors at the moment. Providing care for
stable and uncomplicated patients is within the LPN’s educational preparation and scope
of practice, with the care always being provided under the supervision and direction of the
RN. The RN should assess the newly post-operative patient and the new admission. The
patient who is preparing for discharge after MI may need some complex teaching. Focus:
Delegation/supervision, assignment
27. A. Able to perform self-care activities without pain . By the 2nd day of hospitalization after
suffering a Myocardial Infarction, Clients are able to perform care without chest pain
28. B. Adverse effects of digoxin (Lanoxin) . Toxic levels of Lanoxin stimulate the medullary
chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
29. D. Obtaining infusion pump for the medication . Administration of Intravenous Nitroglycerin
infusion requires pump for accurate control of medication.
30. C. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his
jaw . These are likely signs of an acute myocardial infarction (MI). An acute MI is a
cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not
treated immediately.
31. B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. Nausea is a
symptom of impending myocardial infarction (MI) and should be assessed immediately so
that treatment can be instituted and further damage to the heart is avoided.
32. D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
. Canned fish and vegetables and cured meats are high in sodium. This meal does not
contain any canned fish and/or vegetables or cured meats
33. C. Thrombus formation
34. B. Refocus the conversation on his fears, frustrations and anger about his condition . This
provides the opportunity for the client to verbalize feelings underlying behavior and helpful
in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal
response causing the release of catecholamines that can increase cardiac contractility
and workload that can further increase myocardial oxygen demand.
35. A. Call for help and note the time. Having established, by stimulating the client, that the
client is unconscious rather than sleep, the nurse should immediately call for help. This may
be done by dialing the operator from the client’s phone and giving the hospital code for
cardiac arrest and the client’s room number to the operator, of if the phone is not
available, by pulling the emergency call button. Noting the time is important baseline
information for cardiac arrest procedure.
36. B. Enhance myocardial oxygenation. Enhancing myocardial oxygenation is always the first
priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate
oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to
treat acute angina, but administration isn’t the first priority. Although educating the client
and decreasing anxiety are important in care delivery, neither are priorities when a client is
compromised.
37. C. Oral medication therapy. Oral medication administration is a noninvasive, medical
treatment for coronary artery disease. Cardiac catherization isn’t a treatment, but a
diagnostic tool. Coronary artery bypass surgery and percutaneous transluminal coronary
angioplasty are invasive, surgical treatments.
38. A. Chest pain. The most common symptom of an MI is chest pain, resulting from deprivation
of oxygen to the heart. Dyspnea is the second most common symptom, related to an
increase in the metabolic needs of the body during an MI. Edema is a later sign of heart
failure, often seen after an MI. Palpitations may result from reduced cardiac output,
producing arrhythmias.
39. D. Pulmonary. Pulmonary pain is generally described by these symptoms. Musculoskeletal
pain only increases with movement. Cardiac and GI pains don’t change with respiration.
40. C. Troponin I. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial
injury. Troponin I levels aren’t detectable in people without cardiac injury. Lactate
dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle.
LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood
counts, and a complete chemistry is obtained to review electrolytes. Because CK levels
may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury.
41. D.To decrease oxygen demand on the client’s heart. Morphine is administered because it
decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety
while causing sedation, but it isn’t primarily given for those reasons.
42. C. Coronary artery thrombosis . Coronary artery thrombosis causes an inclusion of the artery,
leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn’t
cause an MI. Renal failure can be associated with MI but isn’t a direct cause. Heart failure is
usually a result from an MI.
43. A.Ventricular dilation. Rapid filling of the ventricle causes vasodilation that is auscultated as
S3. Increased atrial contraction or systemic hypertension can result in a fourth heart sound.
Aortic valve malfunction is heard as a murmur.
44. A. Left-sided heart failure. The left ventricle is responsible for most of the cardiac output. An
anterior wall MI may result in a decrease in left ventricular function. When the left ventricle
doesn’t function properly, resulting in left-sided heart failure, fluid accumulates in the
 interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid
valve malfunction causes right sided heart failure.
45. B. Administer oxygen. Administering supplemental oxygen to the client is the first priority of
care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is
administered to assist in oxygenation and prevent further damage. Morphine and nitro are
also used to treat MI, but they’re more commonly administered after the oxygen. An ECG is
the most common diagnostic tool used to evaluate MI.
46. A. Beta-adrenergic blockers. Beta-adrenergic blockers work by blocking beta receptors in
the myocardium, reducing the response to catecholamines and sympathetic nerve
stimulation. They protect the myocardium, helping to reduce the risk of another infarction
by decreasing myocardial oxygen demand. Calcium channel blockers reduce the
workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen
demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen
consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic
vascular resistance (afterload).
47. C. arrhythmias. Arrhythmias, caused by oxygen deprivation to the myocardium, are the
most common complication of an MI. Cardiogenic shock, another complication of an MI, is
defined as the end stage of left ventricular dysfunction. This condition occurs in
approximately 15% of clients with MI. Because the pumping function of the heart is
compromised by an MI, heart failure is the second most common complication. Pericarditis
most commonly results from a bacterial or viral infection but may occur after the MI.
48. B. Heart failure. Elevated venous pressure, exhibited as jugular vein distention, indicates a
failure of the heart to pump. JVD isn’t a symptom of abdominal aortic aneurysm or
pneumothorax. An MI, if severe enough, can progress to heart failure, however, in and of
itself, an MI doesn’t cause JVD.
49. A. Digoxin. One of the most common signs of digoxin toxicity is the visual disturbance known
as the “green-yellow halo sign.” The other medications aren’t associated with such an
effect.
50. A. Crackles. Crackles in the lungs are a classic sign of left-sided heart failure. These sounds
are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated
with both right- and left-sided heart failure. Left-sided heart failure causes hypertension
secondary to an increased workload on the system.
51. D. Right-sided heart failure. The most accurate area on the body to assess dependent
edema in a bed-ridden client is the sacral area. Sacral, or dependent, edema is secondary
to right-sided heart failure.
52. C. Oliguria. Inadequate deactivation of aldosterone by the liver after right-sided heart
failure leads to fluid retention, which causes oliguria.
53. D. Inotropic agents. Inotropic agents are administered to increase the force of the heart’s
contractions, thereby increasing ventricular contractility and ultimately increasing cardiac
output.
54. B. Tachycardia. Stimulation of the sympathetic nervous system causes tachycardia and
increased contractility. The other symptoms listed are related to the parasympathetic
nervous system, which is responsible for slowing the heart rate.
55. D. Right-sided heart failure. Weight gain, nausea, and a decrease in urine output are
secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a
symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary
symptoms rather than systemic ones. Angina pectoris doesn’t cause weight gain, nausea,
or a decrease in urine output.
56. A. Cardiomyopathy. Cardiomyopathy isn’t usually related to an underlying heart disease
such as atherosclerosis. The etiology in most cases is unknown. CAD and MI are directly
related to atherosclerosis. Pericardial effusion is the escape of fluid into the pericardial sac,
a condition associated with Pericarditis and advanced heart failure.
57. A. Dilated. Although the cause isn’t entirely known, cardiac dilation and heart failure may
develop during the last month of pregnancy or the first few months after birth. The condition
may result from a preexisting cardiomyopathy not apparent prior to pregnancy.
Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an
unknown etiology but a strong familial tendency. Myocarditis isn’t specifically associated
with childbirth. Restrictive cardiomyopathy indicates constrictive pericarditis; the underlying
cause is usually myocardial.
58. C. Hypertrophic. In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum—
not the ventricle chambers—is apparent. This abnormality isn’t seen in other types of
cardiomyopathy.
59. A. Heart failure. Because the structure and function of the heart muscle is affected, heart
failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged
myocardial ischemia due to reduced blood flow through one of the coronary arteries.
Pericardial effusion is most predominant in clients with pericarditis.
60. D. Heart failure. These are the classic signs of failure. Pericarditis is exhibited by a feeling of
fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually
exhibited by headaches, visual disturbances, and a flushed face. MI causes heart failure
but isn’t related to these symptoms.
61. B. Hypertrophic. Cardiac output isn’t affected by hypertrophic cardiomyopathy because
the size of the ventricle remains relatively unchanged. All of the rest decrease cardiac
output.
62. D. Failure of the ventricle to eject all of the blood during systole. An S4 occurs as a result of
increased resistance to ventricular filling after atrial contraction. The increased resistance is
related to decreased compliance of the ventricle. A dilated aorta doesn’t cause an extra
heart sound, though it does cause a murmur. Decreased myocardial contractility is heard
as a third heart sound. An S4 isn’t heard in a normally functioning heart.
63. B. Beta-adrenergic blockers. By decreasing the heart rate and contractility, beta-blockers
improve myocardial filling and cardiac output, which are primary goals in the treatment of
cardiomyopathy. Antihypertensives aren’t usually indicated because they would decrease
cardiac output in clients who are already hypotensive. Calcium channel blockers are
sometimes used for the same reasons as beta-blockers; however, they aren’t as effective as
beta-blockers and cause increased hypotension. Nitrates aren’t used because of their
dilating effects, which would further compromise the myocardium.
64. C. Heart transplantation. The only definitive treatment for cardiomyopathy that can’t be
controlled medically is a heart transplant because the damage to the heart muscle is
irreversible.
65. B. Stable angina. The pain of stable angina is predictable in nature, builds gradually, and
quickly reaches maximum intensity. Unstable angina doesn’t always need a trigger, is more
intense, and lasts longer than stable angina. Variant angina usually occurs at rest—not as a
result of exercise or stress.
66. D. Unstable angina. Unstable angina progressively increases in frequency, intensity, and
duration and is related to an increased risk of MI within 3 to 18 months.
67. D. Inadequate oxygen supply to the myocardium. Inadequate oxygen supply to the
myocardium is responsible for the pain accompanying angina. Increased preload would
be responsible for right-sided heart failure. Decreased afterload causes increased cardiac
output. Coronary artery spasm is responsible for variant angina.
68. D.12-lead electrocardiogram (ECG). The 12-lead ECG will indicate ischemia, showing T-
wave inversion. In addition, with variant angina, the ECG shows ST-segment elevation. A
chest x-ray will show heart enlargement or signs of heart failure, but isn’t used to diagnose
angina.
69. A. Reversal of ischemia. Reversal of the ischemia is the primary goal, achieved by reducing
oxygen consumption and increasing oxygen supply. An infarction is permanent and can’t
be reversed.
70. A. Sit the client down. The initial priority is to decrease the oxygen consumption; this would
be achieved by sitting the client down. An ECG can be obtained after the client is sitting
down. After the ECGm sublingual nitro would be administered. When the client’s condition
is stabilized, he can be returned to bed.
71. C. Preload, afterload, contractility, and heart rate. Myocardial oxygen consumption
increases as preload, afterload, renal contractility, and heart rate increase. Cerebral blood
flow doesn’t directly affect myocardial oxygen consumption.
72. C. In high Fowler’s position. A high Fowler’s position promotes ventilation and facilitates
breathing by reducing venous return. Lying flat and side-lying positions worsen the
breathing and increase workload of the heart. Semi-Fowler’s position won’t reduce the
workload of the heart as well as the Fowler’s position will.
73. D. Hypocapnia. In an attempt to compensate for increased work of breathing due to
hyperventilation, carbon dioxide decreases, causing hypocapnea. If the condition persists,
CO2 retention occurs and hypercapnia results.
74. D. Increased BP and fluid retention. The body compensates for a decrease in cardiac
output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in
blood volume as the kidneys retain sodium and water. Blood pressure doesn’t initially drop
in response to the compensatory mechanism of the body. Alteration in LOC will occur only if
the decreased cardiac output persists.
75. A. Call for help. Production of pink, frothy sputum is a classic sign of acute pulmonary
edema. Because the client is at high risk for decompensation, the nurse should call for help
but not leave the room. The other three interventions would immediately follow.
76. A. Afterload. Afterload refers to the resistance normally maintained by the aortic and
pulmonic valves, the condition and tone of the aorta, and the resistance offered by the
systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled by the
heart per minute. Overload refers to an abundance of circulating volume. Preload is the
volume of blood in the ventricle at the end of diastole.
77. C. Left ventricle. The left ventricle is responsible for the majority of force for the cardiac
output. If the left ventricle is damaged, the output decreases and fluid accumulates in the
interstitial and alveolar spaces, causing pulmonary edema. Damage to the left atrium
would contribute to heart failure but wouldn’t affect cardiac output or, therefore, the onset
of pulmonary edema. If the right atrium and right ventricle were damaged, right-sided
heart failure would result.
78. A. Erythema marginatum, subcutaneous nodules, and fever. Diagnosis of rheumatic fever
requires that the client have either two major Jones criteria or one minor criterion plus
evidence of a previous streptococcal infection. Major criteria include carditis, polyarthritis,
Sydenham’s chorea, subcutaneous nodules, and erythema maginatum (transient,
nonprurtic macules on the trunk or inner aspects of the upper arms or thighs). Minor criteria
include fever, arthralgia, elevated levels of acute phase reactants, and a prolonged PR-
interval on ECG.
79. A. Activate the resuscitation team. Immediately after establishing unresponsiveness, the
nurse should activate the resuscitation team. The next step is to open the airway using the
head-tilt, chin-lift maneuver and check for breathing (looking, listening, and feeling for no
more than 10-seconds). If the client isn’t breathing, give two slow breaths using a bag mask
or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.
80. B. Ineffective tissue perfusion; cardiopulmonary. MI results from prolonged myocardial
ischemia caused by reduced blood flow through the coronary arteries. Therefore, the
priority nursing diagnosis for this client is Ineffective tissue perfusion (cardiopulmonary).
 Anxiety, acute pain, and ineffective therapeutic regimen management are appropriate
but don’t take priority.
81. A. Pulmonary edema. SOB, tachypnea, low BP, tachycardia, crackles, and a cough
producing pink, frothy sputum are late signs of pulmonary edema.
82. D. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is
receiving IV diltiazem (Cardizem). The client with A-fib has the greatest potential to become
unstable and is on IV medication that requires close monitoring. After assessing this client,
the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion,
and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are
resolving and don’t require immediate attention). The lowest priority is the 89-year-old with
end stage right-sided heart failure, who requires time consuming supportive measures.
83. A.“Report fever, anorexia, and night sweats to the physician.” The most essential teaching
point is to report signs of relapse, such as fever, anorexia, and night sweats, to the physician.
To prevent further endocarditis episodes, prophylactic antibiotics are taken before and
sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures. A potassium-
rich diet and daily pulse monitoring aren’t necessary for a client with endocarditis.
84. C. Peptic ulcer disease. Heart failure is precipitated or exacerbated by physical or
emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s
disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and
hypervolemia.
85. B. Digoxin (Lanoxin). Digoxin exerts a positive inotropic effect on the heart while slowing the
overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat
heart failure. Diltiazem (calcium channel blocker) and propranolol and metoprolol (beta
blockers) have a negative inotropic effect and would worsen the failing heart.
86. D. Extremely anxious. Pulmonary edema causes the client to be extremely agitated and
anxious. The client may complain of a sense of drowning, suffocation, or smothering.
87. C. Potassium level. The serum potassium level is measured in the client receiving digoxin and
furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the client
with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.
88. D. Acute renal failure. The client who undergoes cardiac surgery is at risk for renal injury from
poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal
insult is signaled by decreased urine output, and increased BUN and creatinine levels. The
client may need medications such as dopamine (Intropin) to increase renal perfusion and
possibly could need peritoneal dialysis or hemodialysis.
89. B. Premedicate the client with an analgesic. The nurse should encourage regular use of
pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will
promote rest, decrease myocardial oxygen consumption resulting from pain, and allow
better participation in activities such as coughing, deep breathing, and ambulation.
Encouraging the client to cough and deep breathe and providing the client with a walker
will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated
unless prescribed.
90. A. Normal sinus rhythm
91. D. It can develop into ventricular fibrillation at any time. Ventricular tachycardia is a life-
threatening dysrhythmia that results from an irritable ectopic focus that takes over as the
pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral
and myocardial ischemia. Client’s frequently experience a feeling of impending death.
Ventricular tachycardia is treated with antidysrhythmic medications or magnesium sulfate,
cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular
tachycardia can deteriorate into ventricular defibrillation at any time.
92. B. Anorexia, nausea, and visual disturbances. The first signs and symptoms of digoxin toxicity
in adults include abdominal pain, N/V, visual disturbances (blurred, yellow, or green vision,
halos around lights), bradycardia, and other dysrhythmias.
93. C. Variant angina. Stable angina is induced by exercise and is relieved by rest or
nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity and rest, is
less predictable, and is often a precursor of myocardial infarction. Variant angina, or
Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most
often in the morning.
94. A. Obtaining an infusion pump for the medication. IV nitro infusion requires an infusion pump
for precise control of the medication. BP monitoring would be done with a continuous
system, and more frequently than every 4 hours. Hourly urine outputs are not always
required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
95. B. Antithrombotic action. Aspirin does have antipyretic, antiplatelet, and analgesic actions,
but the primary reason ASA is administered to the client experiencing an MI is its
antithrombotic action.
96. D. Can perform personal self-care activities without pain. By day 2 of hospitalization after an
MI, clients are expected to be able to perform personal care without chest pain. Day 2
hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a
walking program; however, the client may be sitting up in a chair as part of the cardiac
rehabilitation program. Severe chest pain should not be present.
97. B. Small, easily digested meals. Recommended dietary principles in the acute phase of MI
include avoiding large meals because small, easily digested foods are better digested
foods are better tolerated. Fluids are given according to the client’s needs, and sodium
restrictions may be prescribed, especially for clients with manifestations of heart failure.
Cholesterol restrictions may be ordered as well. Clients are not prescribed a diet of liquids
only or NPO unless their condition is very unstable.
98. A. Left ventricular atrophy. In older adults who are less active and do not exercise the heart
muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the
myocardium of the older adult. As a result, under sudden emotional or physical stress, the
left ventricle is less able to respond to the increased demands on the myocardial muscle.
99. A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output. and C. Decreased cardiac output related to structural and
functional changes. HF is a result of structural and functional abnormalities of the heart
tissue muscle. The heart muscle becomes weak and does not adequately pump the blood
out of the chambers. As a result, blood pools in the left ventricle and backs up into the left
atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the
ventricle after contraction thereby decreasing cardiac output. In addition, this pooling
leads to thrombus formation and ineffective tissue perfusion because of the decrease in
blood flow to the other organs and tissues of the body. Typically, these clients have an
ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related
to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the
decrease in cardiac output triggers compensatory mechanisms, such as an increase in
sympathetic nervous system activity.
100. C. Activity intolerance related to pump failure. Activity intolerance is a primary problem
for clients with heart failure and pulmonary edema. The decreased cardiac output
associated with heart failure leads to reduced oxygen and fatigue. Clients frequently
complain of dyspnea and fatigue. The client could be at risk for infection related to stasis of
secretions or impaired skin integrity related to pressure. However, these are not the priority
nursing diagnoses for the client with HF and pulmonary edema, nor is constipation related
to immobility.
101. C. Vasodilator. ACE inhibitors have become the vasodilators of choice in the client with
mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve
survival in overt heart failure.
102. A. 5 to 10 minutes. After IV injection of furosemide, diuresis normally begins in about 5
minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.
103. B. Tomato juice. Canned foods and juices, such as tomato juice, are typically high in
sodium and should be avoided in a sodium-restricted diet.
104. B. Left ventricular enlargement. A normal apical impulse is found under over the apex of
the heart and is typically located and auscultated in the left fifth intercostal space in the
midclavicular line. An apical impulse located or auscultated below the fifth intercostal
space or lateral to the midclavicular line may indicate left ventricular enlargement.