1.

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
2. Medical treatment of coronary artery disease includes which of the following
procedures?
A Coronary artery bypass surgery
B Oral medication therapy
C Percutaneous transluminal coronary angioplasty
3. Which of the following is the most common symptom of myocardial infarction (MI)?
A Chest pain
B Dyspnea
C Edema
D Palpitations
4. 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
5. 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)
6. 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
7. Which of the following conditions is most commonly responsible for myocardial
infarction?
A Aneurysm
B Heart failure
C Coronary artery thrombosis
D Renal failure
8. 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
9. 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
10. What is the first intervention for a client experiencing MI?
A Administer morphine
B Administer oxygen
C Administer sublingual nitroglycerin
D Obtain an ECG
11. 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
12. What is the most common complication of an MI?
A Cardiogenic shock
B Heart failure
C Arrhythmias
D Pericarditis
13. 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)
14. Which of the following classes of medications maximizes cardiac performance in
clients with heart failure by increasing ventricular contractility?
A Beta-adrenergic blockers
B Calcium channel blockers
C Diuretics
D Inotropic agents
15. Stimulation of the sympathetic nervous system produces which of the following
responses?
A Bradycardia
B Tachycardia
C Hypotension
D Decreased myocardial contractility
16. 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
17. Which of the following types of cardiomyopathies can be associated with childbirth?
A Dilated
B Hypertrophic
C Myocarditis
D Restrictive
18. Septal involvement occurs in which type of cardiomyopathy?
A Congestive
B Dilated
C Hypertrophic
D Restrictive
19. Which of the following recurring conditions most commonly occurs in clients with
cardiomyopathy?
A Heart failure
B Diabetes
C MI
D Pericardial effusion
20. In which of the following types of cardiomyopathies does cardiac output remain
normal?
A Dilated
B Hypertrophic
C Obliterative
D Restrictive
21. Which of the following cardiac conditions does a fourth heart sound (S4) 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
22. 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
23. If medical treatments fail, which of the following invasive procedures is necessary for
treating cardiomyopathy?
A Cardiac catheterization
B Coronary artery bypass graft (CABG)
C Heart transplantation
D Intra-aortic balloon pump (IABP)
24. Which of the following types of angina is most closely related with an impending MI?
A Angina decubitus
B Chronic stable angina
 C Nocturnal angina
D Unstable angina
25. Which of the following tests is used most often to diagnose angina?
A Chest x-ray
B Echocardiogram
C Cardiac catheterization
D 12-lead electrocardiogram (ECG)
26. 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
27. 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.
28. 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
29. A client admitted with angina complains 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
30. 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
31. 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).
32. 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
33. 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
34. 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.
35. 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
36. 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
37. Aspirin is administered to the client experiencing an MI because of its:
A Antipyretic action
B Antithrombotic action
C Antiplatelet action
D Analgesic action
38. 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
39. 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
40. 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
41. 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.
42. 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
43. 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
44. 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
45. A pregnant client in the last trimester has been admitted to the hospital with a
diagnosis of severe preeclampsia. A nurse monitors for complications associated with
the diagnosis and assesses the client for:
A Any bleeding, such as in the gums, petechiae, and purpura.
B Enlargement of the breasts
C Periods of fetal movement followed by quiet periods
D Complaints of feeling hot when the room is cool
46. A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia
and who is being monitored for pregnancy induced hypertension (PIH). Which
assessment finding indicates a worsening of the Preeclampsia and the need to notify
the physician?
A Blood pressure reading is at the prenatal baseline
B Urinary output has increased
C The client complains of a headache and blurred vision
D Dependent edema has resolved
47. A primigravida is receiving magnesium sulfate for the treatment of pregnancy
induced hypertension (PIH). The nurse who is caring for the client is performing
assessments every 30 minutes. Which assessment finding would be of most concern
to the nurse?
A Urinary output of 20 ml since the previous assessment
B Deep tendon reflexes of 2+
C Respiratory rate of 10 BPM
D Fetal heart rate of 120 BPM
48. A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of
care for the client and documents in the plan that if the client progresses from
Preeclampsia to eclampsia, the nurse's first action is to:
A Administer magnesium sulfate intravenously
B Assess the blood pressure and fetal heart rate
C Clean and maintain an open airway
D Administer oxygen by face mask
49. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is
at risk for Preeclampsia. The nurse checks the client for which specific signs of
Preeclampsia (select all that apply)?
A Elevated blood pressure
B Negative urinary protein
C Facial edema
D Increased respirations
50. A pregnant client is receiving magnesium sulfate for the management of
preeclampsia. A nurse determines the client is experiencing toxicity from the
medication if which of the following is noted on assessment?
A Presence of deep tendon reflexes
B Serum magnesium level of 6 mEq/L
C Proteinuria of +3
D Respirations of 10 per minute
51. A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to
care for the client determines that the magnesium therapy is effective if:
A Ankle clonus in noted
B The blood pressure decreases
C Seizures do not occur
D Scotomas are present
52. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV
magnesium sulfate. Select all nursing interventions that apply in the care for the
client.
A Monitor maternal vital signs every 2 hours
B Notify the physician if respirations are less than 18 per minute.
C Monitor renal function and cardiac function closely
D Keep calcium gluconate on hand in case of a magnesium sulfate overdose
E Monitor deep tendon reflexes hourly
F Monitor I and O's hourly
G Notify the physician if urinary output is less than 30 ml per hour.
53. The antagonist for magnesium sulfate should be readily available to any client
receiving IV magnesium. Which of the following drugs is the antidote for magnesium
toxicity?
A Calcium gluconate
B Hydralazine (Apresoline)
C Narcan
D RhoGAM
54. 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.
55. 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.
56. 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
 57. A maternity nurse is caring for a client with abruptio placenta and is monitoring the
client for disseminated intravascular coagulopathy. Which assessment finding is least
likely to be associated with disseminated intravascular coagulation?
A Swelling of the calf in one leg
B Prolonged clotting times
C Decreased platelet count
D Petechiae, oozing from injection sites, and hematuria

Answer Key:
1. 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.
2. B. Oral medication therapy
Oral medication administration is a noninvasive, medical treatment for coronary
artery disease. Cardiac catheterization isn't a treatment, but a diagnostic tool.
Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty
are invasive, surgical treatments.
3. A. Chest pain
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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).
12. 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.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. 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
cardiomyopathies.
19. 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.
20. 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.
21. 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.
22. 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.
23. 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.
24. 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.
25. 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.
26. 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.
27. 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.
28. 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.
29. 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.
30. 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.
31. 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.
32. 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.
33. B. Remove telemetry equipment because it weighs down the hospital gown
 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. Options 1 and 3 will not help in tolerating
ambulation. Removal of telemetry equipment is contraindicated unless prescribed.
34. 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
antiarrhythmic medications or magnesium sulfate, cardioversion (client awake), or
defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into
ventricular fibrillation at any time.
35. 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.
36. 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.
37. 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.
38. 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.
39. 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.
40. 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.
41. A. Ineffective tissue perfusion related to decreased peripheral blood flow
secondary to decreased cardiac output.
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.
42. 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.
43. 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.
44. 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.
45. A. Any bleeding, such as in the gums, petechiae, and purpura.
Severe Preeclampsia can trigger disseminated intravascular coagulation because of
the widespread damage to vascular integrity. Bleeding is an early sign of DIC and
should be reported to the M.D.
46. C. The client complains of a headache and blurred vision
If the client complains of a headache and blurred vision, the physician should be
notified because these are signs of worsening Preeclampsia.
47. C. Respiratory rate of 10 BPM
Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12
breaths per minute, the physician or other health care provider needs to be notified,
and continuation of the medication needs to be reassessed. A urinary output of 20 ml
in a 30-minute period is adequate; less than 30 ml in one hour needs to be reported.
Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus.
48. C. Clean and maintain an open airway
 The immediate care during a seizure (eclampsia) is to ensure a patent airway. The
other options are actions that follow or will be implemented after the seizure has
ceased.
49. A. Elevated blood pressure.
C. Facial edema
The three classic signs of preeclampsia are hypertension, generalized edema, and
proteinuria. Increased respirations are not a sign of preeclampsia.

50. D. Respirations of 10 per minute

Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity
relate to the central nervous system depressant effects of the medication and include
respiratory depression, loss of deep tendon reflexes, and a sudden drop in the fetal
heart rate and maternal heart rate and blood pressure. Therapeutic levels of
magnesium are 4-7 mEq/L. Proteinuria of +3 would be noted in a client with
preeclampsia.
51. C. Seizures do not occur
For a client with preeclampsia, the goal of care is directed at preventing eclampsia
(seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent.
Although a decrease in blood pressure may be noted initially, this effect is usually
transient. Ankle clonus indicated hyperreflexia and may precede the onset of
eclampsia. Scotomas are areas of complete or partial blindness. Visual disturbances,
such as scotomas, often precede an eclamptic seizure.
52. C. Monitor renal function and cardiac function closely
D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
E. Monitor deep tendon reflexes hourly
F. Monitor I and O's hourly
G. Notify the physician if urinary output is less than 30 ml per hour.
When caring for a client receiving magnesium sulfate therapy, the nurse would
monitor maternal vital signs, especially respirations, every 30-60 minutes and notify
the physician if respirations are less than 12, because this would indicate respiratory
depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose,
because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep
tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely.
The urine output should be maintained at 30 ml per hour because the medication is
eliminated through the kidneys.
53. A. Calcium gluconate
Calcium gluconate is the antidote for magnesium toxicity. Ten ml of 10% calcium
gluconate is given IV push over 3-5 minutes. Hydralazine is given for sustained
elevated blood pressures in preeclamptic clients.
54. 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.
55. 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.
56. 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.

57. A. Swelling of the calf in one leg

DIC is a state of diffuse clotting in which clotting factors are consumed, leading to
widespread bleeding. Platelets are decreased because they are consumed by the
process; coagulation studies show no clot formation (and are thus normal to
prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in
an isolated area. The presence of petechiae, oozing from injection sites, and hematuria
are signs associated with DIC. Swelling and pain in the calf of one leg are more likely
to be associated with thrombophlebitis.