1. The nurse receives report on the medical/surgical unit.

Which of the following clients should the

nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at
the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf pain with movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air.
4. A client 12 hours after a hysterectomy complaining of nausea.
2. The nurse learns that patients from a motor vehicle accident are being transferred to the emergency
department (ED). The nurse performs triage in the ED. Which of the following patients should the
nurse see FIRST?
1. A patient with ecchymosis and lacerations to the facial area.
2. A patient complaining of shortness of breath and pressure in the chest.
3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm.
4. A patient complaining of dizziness and nervousness.
3. The nurse is seeing patients in the medical/surgical unit. Which of the following patients should the
nurse see FIRST?
1. A patient diagnosed with heart failure who has received 800 ml of IV fluids in 2 hours.
2. A patient diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL.
3. A patient diagnosed with hypertension requiring the 9 A.M. dose of captopril (Capoten).
4. A patient postoperative after a laminectomy who requires supervision when ambulating.
4. The nurse cares for clients on the medical/surgical unit. After receiving report, which of the
following clients should the nurse see FIRST?
1. An elderly client 2 days postop after a total hip replacement who slipped out of bed when trying to
stand.
2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast.
3. An elderly client diagnosed with a right-sided CVA who requires assistance going to the
bathroom.
4. An elderly client diagnosed with heart failure (HF) who has been vomiting for 3 days.
5. A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides
discharge instructions to a patient and his family. Which misunderstanding by the family indicates
the need for more detailed information?
A. The patient may resume normal home activities as tolerated but should avoid physical exertion
and get adequate rest.
B. The patient should resume a normal diet with emphasis on nutritious, healthy foods.
C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have
completely resolved.
D. The patient should continue use of the incentive spirometer to keep airways open and free of
secretions.
6. The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is
the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a
pacemaker prior to discharge.
B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency
Department and scheduled for an angiogram.
C. A patient with unstable angina being closely monitored for pain and medication titration.
D. A post-operative valve replacement patient who was recently admitted to the unit because all
surgical beds were filled.
7. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected
bowel obstruction. Which of the following arterial blood gas results might be expected in this
patient?
A. pH 7.52, PCO2 54 mm Hg.
 B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg.
8. With which of the following disorders is jugular vein distention most prominent?
1. Abdominal aortic aneurysm
2. Heart failure
3. MI
4. Pneumothorax
9. Which of the following symptoms is most commonly associated with left-sided heart failure?
1. Crackles
2. Arrhythmias
3. Hepatic engorgement
4. Hypotension
10. Which of the following symptoms might a client with right-sided heart failure exhibit?
1. Adequate urine output
2. Polyuria
3. Oliguria
4. Polydipsia
11. Which of the following conditions is most closely associated with weight gain, nausea, and a
decrease in urine output?
1. Angina pectoris
2. Cardiomyopathy
3. Left-sided heart failure
4. Right-sided heart failure
12. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the
following conditions?
1. Pericarditis
2. Hypertension
3. MI
4. Heart failure
13.  Which of the following is a compensatory response to decreased cardiac output?
1. Decreased BP
2. Alteration in LOC
3. Decreased BP and diuresis
4. Increased BP and fluid retention
14. Which of the following actions is the appropriate initial response to a client coughing up pink, frothy
sputum?
1. Call for help
2. Call the physician
3. Start an I.V. line
4. Suction the client
15. Acute pulmonary edema caused by heart failure is usually a result of damage to which of the
following areas of the heart?
1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle
16. 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?
 1. Pulmonary edema
2. Pneumothorax
3. Cardiac tamponade
4. Pulmonary embolus
17. 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?
1. 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.
2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order.
3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV
heparin.
4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is
receiving IV diltiazem (Cardizem).
18. An elderly client is being monitored for evidence of congestive heart failure. To detect early signs of
heart failure, the nurse would instruct the certified nursing attendant (CNA) to do which of the
following during care of the patient?
1. Observe electrocardiogram readings and report deviations to the nurse.
2. Assist the client with ambulation three times during the shift.
3. Monitor vital signs every 15 minutes and report each reading to the nurse.
4. Accurately weigh the patient, and report and record the readings.
Answer Key:
1. Strategy: Determine the most unstable client.
(1) assess site for client's comfort and to prevent complications associated with IV infusion, probable
DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported to the physician
immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
2. Strategy: Determine the most unstable patient.
(1) does not require immediate attention
(2) potential problems; not the most unstable
(3) CORRECT— vital signs indicate shock; most unstable patient
(4) most stable patient of the four; use Maslow hierarchy of needs theory to prioritize; physiological
needs take priority; use ABCs
3. Strategy: Determine the most unstable patient.
(1) CORRECT— assess for circulatory overload
(2) normal range is 8.5 to 10.5 mg/dL
(3) can give 30 min before or after prescribed time; ACE inhibitor
(4) nothing to indicate patient is unstable
4. Strategy: Determine the most unstable patient.
(1) CORRECT— assess for circulatory overload
(2) normal range is 8.5 to 10.5 mg/dL
(3) can give 30 min before or after prescribed time; ACE inhibitor
(4) nothing to indicate patient is unstable
5. Answer: C
It is always critical that patients being discharged from the hospital take prescribed medications as
instructed. In the case of antibiotics, a full course must be completed even after symptoms have
resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient
should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the
incentive spirometer after discharge will speed recovery and improve lung function.
6. Answer: A
The charge nurse planning assignments must consider the skills of the staff and the needs of the
patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients
should be assigned to those with the least acute needs. The patient who is one-week post-operative
and nearing discharge is likely to require routine care. A new patient admitted with suspected MI
and scheduled for angiography would require continuous assessment as well as coordination of care
that is best carried out by experienced staff. The unstable patient requires staff that can immediately
identify symptoms and respond appropriately. A post-operative patient also requires close
monitoring and cardiac experience.
7. Answer: A
A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric
acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents
alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is
borderline normal with slightly low PCO2.
8. Answer: 2
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.
9. Answer: 1
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.
10. Answer: 3
Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid
retention, which causes oliguria.
11. Answer: 4
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.
12. Answer: 4
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.
13. Answer: 4
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.
14. Answer: 1
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.
15. Answer: 3
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 accumulate 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.
16. Answer: 1
SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink, frothy sputum are late
signs of pulmonary edema.
17. Answer: 4
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.
18. Answer: 4
Rationale: Due to fluid accumulation, an expanded blood volume can result when the heart fails.
Body weight is a sensitive indicator of water and sodium retention, which will manifest itself with
edema, dyspnea - especially nocturnal - and pedal edema. Patients also should be instructed about
the need to perform daily weights upon discharge to monitor body water. It is not within the role of
the CNA to monitor ECG readings, and ambulation is not an assessment. Vital signs every 15 minute
are not necessary for this level of patient care.