Question
1.The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager?
A. Discuss personal information the client shared with the nurse in confidence
B. Provide the case manager with any information that is required for continuity of care
C. Explain that client confidentiality prevents the nurse from disclosing information.
D. Ask the case manager to get the client’s permission before sharing information
2. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement?
A. Call a code blue immediately
B. Check the patient’s telemetry leads
C. Find the nurse to check the client
D. Remove the telemetry monitor
3. The charge nurse is making assignments for a 30-bed cardiac unit staffed with three RNs, three LPNs, and three UAPs. Which assignment is most appropriate by the charge nurse?
A. Assign a RN to perform all sterile procedures
B. Assign a LPN to give all IV medications
C. Assign an UAP to complete the a.m. care
D. Assign a LPN to write the care plans.
4. The charge nurses making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
A. The 44 y/o client diagnosed with a myocardial infarction
B. The 65 y/o client admitted with unstable angina
C. The 75 y/o client scheduled for a cardiac catheterization
D. The 50 y/o client complaining of chest pain
5. Which client should the telemetry nurse assess first after receiving the a.m. shift report?
A. The client diagnosed with DVT who has an edematous right calf.
B. The client diagnosed with mitral valve stenosis who has heart palpitations
C. The client diagnosed with arterial occlusive disease who has intermittent claudication.
D. The client diagnosed with congestive heart failure who has pink frothy sputum
6. The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?
A. The cardiac glycoside to the client who has an apical pulse of 58
B. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L
C. The antidysrhythmic to the client in ventricular fibrillation
D. The calcium-channel blocker who has a blood pressure of 110/68
7. The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?
A. The client who has just been brought to the unit from the ED with no report of complaints.
B. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale.
C. The client who had a cardiac cauterization in the morning and has palpable pedal pulses bilaterally
D. The client who has been turning on the call light frequently and stated her care has been neglected
B. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale.
C. The client who had a cardiac cauterization in the morning and has palpable pedal pulses bilaterally
D. The client who has been turning on the call light frequently and stated her care has been neglected
8. The charge nurse on the cardiac unit has to float a nurse to the ED for the shift. Which nurse should be floated to the ED?
A. The nurse who has 4 years of experience in the cardiac unit
B. The nurse who just transferred from critical care to the cardiac unit
C. The nurse with 1 year of experience on the cardiac unit who has. been on a week’s sick leave.
D. The nurse who has working in the OR for 2 years and in the cardiac unit for 3 years
A. The nurse who has 4 years of experience in the cardiac unit
B. The nurse who just transferred from critical care to the cardiac unit
C. The nurse with 1 year of experience on the cardiac unit who has. been on a week’s sick leave.
D. The nurse who has working in the OR for 2 years and in the cardiac unit for 3 years
B. The nurse who just transferred from critical care to the cardiac unit.
(most critical care experience)
(most critical care experience)
9. The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority.
A. Infuse the unit of blood at 20 gtts/min the first 15 minutes
B. Check the unit of blood and the client’s blood band with another nurse
C. Initiate Y-tubing with normal saline via an 18-gauge angiocatheter
D. Assess the client’s vital signs and lung sounds, and assess for a rash
E. Obtain informed consent for the unit of blood from the client
A. Infuse the unit of blood at 20 gtts/min the first 15 minutes
B. Check the unit of blood and the client’s blood band with another nurse
C. Initiate Y-tubing with normal saline via an 18-gauge angiocatheter
D. Assess the client’s vital signs and lung sounds, and assess for a rash
E. Obtain informed consent for the unit of blood from the client
E, D, C, B, A
1. obtain informed consent
2. assess VS, lung sounds, and assess for rash
3. initiate y-tubing with 18-gauge IV
4. check the unit of blood and the blood band with another nurse
5. infuse the unit of blood at 20 gtts/min the first 15 minutes
1. obtain informed consent
2. assess VS, lung sounds, and assess for rash
3. initiate y-tubing with 18-gauge IV
4. check the unit of blood and the blood band with another nurse
5. infuse the unit of blood at 20 gtts/min the first 15 minutes
10. The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?
A. The client with CAD who is complaining that the nurses are being rude and won’t answer the call lights
B. The client diagnosed with an acute MI who has an elevated creatinine phospholkinase-cardiac muscle (CPK-MB) level
C. The client diagnosed with a fib on an oral anticoagulant who has an INR of 2.8
D. The client 2 days post-op CABG who is being transferred to the cardiac unit
A. The client with CAD who is complaining that the nurses are being rude and won’t answer the call lights
B. The client diagnosed with an acute MI who has an elevated creatinine phospholkinase-cardiac muscle (CPK-MB) level
C. The client diagnosed with a fib on an oral anticoagulant who has an INR of 2.8
D. The client 2 days post-op CABG who is being transferred to the cardiac unit
11. The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe CHF who is receiving D5W/0.9 NaCL at 25 ml/hr. Rank in order of importance.
A. Administer the medication over 5 minutes
B. Dilute the medication with normal saline
C. Draw up the medication in a tuberculin syringe
D. Check the client’s ID band
E. Clamp the primary tubing distal to the port
A. Administer the medication over 5 minutes
B. Dilute the medication with normal saline
C. Draw up the medication in a tuberculin syringe
D. Check the client’s ID band
E. Clamp the primary tubing distal to the port
C, B, D, E, A
12. The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and b/p increases to 210/130. Which intervention should the ICU nurse implement first?
A. Discontinue the client’s vasoconstrictor, dopamine
B. Notify the client’s HCP
C. Administer the vasopressor hydralazine
D. Assess the client’s neuro status
A. Discontinue the client’s vasoconstrictor, dopamine
B. Notify the client’s HCP
C. Administer the vasopressor hydralazine
D. Assess the client’s neuro status
13. The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse?
A. The client with acute rheumatic fever carditis who does not want to stay on bed rest
B. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22
C. The client who is showing multifocal PVCs
D. The client diagnosed with angina who is scheduled for a cardiac catheterization
A. The client with acute rheumatic fever carditis who does not want to stay on bed rest
B. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22
C. The client who is showing multifocal PVCs
D. The client diagnosed with angina who is scheduled for a cardiac catheterization
14. The primary cardiac nurse is delegating tasks to the UAP. Which delegation task warrants intervention by the charge nurse of the cardiac unit?
A. The UAP is instructed to bathe the client who is on telemetry
B. The UAP is requested to obtain a bedside glucometer reading
C. The UAP is asked to assist with a portable chest x-ray
D. The UAP is told to feed a client who is dysphagic
A. The UAP is instructed to bathe the client who is on telemetry
B. The UAP is requested to obtain a bedside glucometer reading
C. The UAP is asked to assist with a portable chest x-ray
D. The UAP is told to feed a client who is dysphagic
15. The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication?
A. The client receiving a calcium-channel blocker who is drinking a glass of grapefruit juice
B. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 bpm
C. The client receiving NSAIDs who has just finished eating breakfast
D. The client receiving an oral anticoagulant who has an INR of 2.8
A. The client receiving a calcium-channel blocker who is drinking a glass of grapefruit juice
B. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 bpm
C. The client receiving NSAIDs who has just finished eating breakfast
D. The client receiving an oral anticoagulant who has an INR of 2.8
16. The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times fo the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy?
A. The charge nurse terminated the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit
B. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift
C. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated
D. The staff nurse asks another staff member to talk to the charge nurse to explain that she is available part of the team
A. The charge nurse terminated the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit
B. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift
C. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated
D. The staff nurse asks another staff member to talk to the charge nurse to explain that she is available part of the team
17. Which client warrants immediate intervention by the nurse?
A. The client diagnosed with pericarditis who has chest pain with inspiration
B. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse
C. The client diagnosed with Marfan syndrome who has precuts excavatum
D. The client diagnosed with atherosclerosis who has slurred speech and drooling
A. The client diagnosed with pericarditis who has chest pain with inspiration
B. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse
C. The client diagnosed with Marfan syndrome who has precuts excavatum
D. The client diagnosed with atherosclerosis who has slurred speech and drooling
18. The UAP working in a long-term care facility notifies the nurse that the client diagnosed with CHF who is on a low-Na+ diet is complaining that the food is inedible. Which intervention should the nurse implement first?
A. Have the family bring food from home for the client
B. Check to see what the client has eaten in the past 24 hours
C. Tell the client that low-Na+ diet is an important part of the diagnosis.
D. Ask the dietician to discuss food preferences with the client
A. Have the family bring food from home for the client
B. Check to see what the client has eaten in the past 24 hours
C. Tell the client that low-Na+ diet is an important part of the diagnosis.
D. Ask the dietician to discuss food preferences with the client
19. The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse?
A. The client diagnosed with mitral valve stenosis
B. The client diagnosed with asymptomatic sinus bradycardia
C. The client diagnosed with fulminant pulmonary edema
D. The client diagnosed with acute a fib
A. The client diagnosed with mitral valve stenosis
B. The client diagnosed with asymptomatic sinus bradycardia
C. The client diagnosed with fulminant pulmonary edema
D. The client diagnosed with acute a fib
20. The evening nurse in a long-term care facility is preparing to administer medications to a client diagnosed with a fib and INR of 3.4. Which medication should the nurse question administering?
A. Warfarin (Coumadin), an anticoagulant
B. Metoclopramide (Reglan), a gastric motility medication
C. Docusate (colace), a stool softener
D. Atorvastatin (Lipitor), an antihyperlipidemic
A. Warfarin (Coumadin), an anticoagulant
B. Metoclopramide (Reglan), a gastric motility medication
C. Docusate (colace), a stool softener
D. Atorvastatin (Lipitor), an antihyperlipidemic
21. The nurse and the UAP enter the client’s room and discover that the client is unresponsive. Which action, according to the American Heart Association guidelines, should the nurse assign to the UAP first?
A. Ask the UAP to check wether the client is asleep
B. Tell the UAP to perform cardiac compressions
C. Instruct the UAP to get the crash cart
D. Request the UAP to put the client in a recumbent position
A. Ask the UAP to check wether the client is asleep
B. Tell the UAP to perform cardiac compressions
C. Instruct the UAP to get the crash cart
D. Request the UAP to put the client in a recumbent position
22. The elderly client on a cardiac unit has a DNR order written. Which intervention should the nurse implement?
A. Continue to care for the client’s needs as usual
B. Place notification of the DNR inside the client’s chart
C. Refer the client to a hospice organization
D. Limit visitors to two at a time, so as not to tire the client
A. Continue to care for the client’s needs as usual
B. Place notification of the DNR inside the client’s chart
C. Refer the client to a hospice organization
D. Limit visitors to two at a time, so as not to tire the client
23. The nurse is initiating discharge teaching to a 68 y/o male client who had a quadruple CABG. Which priority question should the nurse ask the client?
A. “Are you sexually active?”
B. “Can you still drive your car?”
C. “Do you have pain medications at home?”
D. “Do you know when to call your HCP?”
A. “Are you sexually active?”
B. “Can you still drive your car?”
C. “Do you have pain medications at home?”
D. “Do you know when to call your HCP?”
23. The LPN informs the clinic nurse that the client diagnosed with a fib has an INR of 4.5. Which intervention should the nurse implement?
A. Tell the LPN to notify the clinic HCP
B. Instruct the LPN to assess the client for abdominal bleeding
C. Obtain a state EKG one the client
D. Take no action because this INR is within normal range
A. Tell the LPN to notify the clinic HCP
B. Instruct the LPN to assess the client for abdominal bleeding
C. Obtain a state EKG one the client
D. Take no action because this INR is within normal range
24. The nurse at a disaster site is triaging victims when a woman states, “I am a certified nursing aide. Can I do something to help?” Which action should the nurse implement?
A. Request the woman to please leave the area
B. Ask the woman to check the injured clients
C. Tell the woman to try and keep the victims calm
D. Instruct the woman to help the paramedics
A. Request the woman to please leave the area
B. Ask the woman to check the injured clients
C. Tell the woman to try and keep the victims calm
D. Instruct the woman to help the paramedics
25. The cardiac clinic nurse hears the UAP tell the client, “You have gained over 15 pounds since your last visit.” The scale is located in the office area. Which action should the clinic nurse implement?
A. Tell the UAP in front of the client to not comment on weight
B. Ask the UAP to put the client in the room and take no action
C. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA
D. Report the UAP to the director of nurses of the clinic
A. Tell the UAP in front of the client to not comment on weight
B. Ask the UAP to put the client in the room and take no action
C. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA
D. Report the UAP to the director of nurses of the clinic
26. The nurse on the cardiac unit is discussing case management with a client who asks, “Why do I need a case manager for my heart disease?” Which statements are most appropriate for the nurse to respond? *Select all that apply*
A. “Case management helps contain the costs of your healthcare.”
B. “It will help enhance your quality of life with a chronic illness.”
C. “It decreases the fragmentation of care across many healthcare settings.”
D. “Case management is a form of health insurance for clients with chronic illness.”
E. “We try to provide quality of care along the healthcare continuum.”
A. “Case management helps contain the costs of your healthcare.”
B. “It will help enhance your quality of life with a chronic illness.”
C. “It decreases the fragmentation of care across many healthcare settings.”
D. “Case management is a form of health insurance for clients with chronic illness.”
E. “We try to provide quality of care along the healthcare continuum.”
27. The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse?
A. “I have to go to the bathroom a lot during the morning.”
B. “I get up very slowly when I have been sitting down for a while.”
C. “I do not salt my food when I am cooking it but I add it at the table.”
D. “I drink grapefruit juice every morning with my breakfast.”
A. “I have to go to the bathroom a lot during the morning.”
B. “I get up very slowly when I have been sitting down for a while.”
C. “I do not salt my food when I am cooking it but I add it at the table.”
D. “I drink grapefruit juice every morning with my breakfast.”
28. The director of nurses in the cardiac unit is counseling an UAP in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy?
A. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early
B. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week
C. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly
D. The UAP is placed on 1-month probation, and any further occurrences will result in termination from this position
A. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early
B. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week
C. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly
D. The UAP is placed on 1-month probation, and any further occurrences will result in termination from this position
29. The cardiac clinic nurse has told the female UAP twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first?
A. Tell the UAP to change it immediately
B. Ask the UAP why the sharps container has not been changed
C. Change the sharps container as per clinic policy
D. Document the situation and place a copy of the documentation in the employee file
A. Tell the UAP to change it immediately
B. Ask the UAP why the sharps container has not been changed
C. Change the sharps container as per clinic policy
D. Document the situation and place a copy of the documentation in the employee file
30. The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won’t go to the hospital. Which action should the nurse implement first?
A. Instruct the wife to call 911 immediately
B. Tell the wife to have the client chew an aspirin
C. Ask the wife what the client had to eat recently
D. Request the husband to talk to the clinic nurse
A. Instruct the wife to call 911 immediately
B. Tell the wife to have the client chew an aspirin
C. Ask the wife what the client had to eat recently
D. Request the husband to talk to the clinic nurse
31. The home health nurse received phone messages from the agency secretary. Which client should the nurse phone first?
A. The client diagnosed with hypertension who is reporting a bp of 148/92
B. The client diagnosed with cardiomyopathy who has a pulse ox reading of 93%
C. The client diagnosed with CHF who has edematous feet
D. The client diagnosed with chronic a fib who is having chest pain
A. The client diagnosed with hypertension who is reporting a bp of 148/92
B. The client diagnosed with cardiomyopathy who has a pulse ox reading of 93%
C. The client diagnosed with CHF who has edematous feet
D. The client diagnosed with chronic a fib who is having chest pain
32. The client is diagnosed with end-stage CHF. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement?
A. Assist the client to the sitting position
B. Assess the client’s vital signs
C. Call 911 for the paramedics
D. Auscultate the client’s lung sounds
A. Assist the client to the sitting position
B. Assess the client’s vital signs
C. Call 911 for the paramedics
D. Auscultate the client’s lung sounds
33. We have an expert-written solution to this problem!
The home health nurse is visiting a client diagnosed with CHF. The client has an out-of-hospital DNR order, has stopped breathing, and has non pulse or blood pressure. The client’s family is at the bedside. Which intervention should the home health nurse implement first?
A. Contact the agency’s chaplain
B. Pronounce the client’s death
C. Ask the family to leave the bedside
D. Call the client’s funeral home
A. Contact the agency’s chaplain
B. Pronounce the client’s death
C. Ask the family to leave the bedside
D. Call the client’s funeral home
34. The cardiac nurse received lab results on the following clients. Which client warrants immediate intervention from the nurse?
A. The client who has an INR of 2.8
B. The client who has a serum potassium level of 3.8 mEq/L
C. The client who has a serum digoxin level of 2.6 mg/dL
D. The client who has a glycosated hemoglobin of 6%
A. The client who has an INR of 2.8
B. The client who has a serum potassium level of 3.8 mEq/L
C. The client who has a serum digoxin level of 2.6 mg/dL
D. The client who has a glycosated hemoglobin of 6%
35. The home health nurse is completing the admission assessment for an obese client diagnosed with a MI with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement?
A. Encourage the client to walk 30 minutes a day
B. Request a home health-registered dietician to talk to the client
C. Refer the client to a cardiac rehabilitation unit
D. Discuss the client’s need to lose 1 to 2 pounds a week
A. Encourage the client to walk 30 minutes a day
B. Request a home health-registered dietician to talk to the client
C. Refer the client to a cardiac rehabilitation unit
D. Discuss the client’s need to lose 1 to 2 pounds a week
36. The home health nurse is preparing for the initial visit to a client diagnosed with CHF. Which intervention should the home health nurse implement first?
A. Prepare all the needed equipment for the visit
B. Call the client to arrange a time for the visit
C. Review the client’s referral form/pertinent data
D. Make the necessary referrals for the client.
A. Prepare all the needed equipment for the visit
B. Call the client to arrange a time for the visit
C. Review the client’s referral form/pertinent data
D. Make the necessary referrals for the client.
37. Which information should the experienced home health nurse discuss when orienting a new nurse to home health nursing?
A. If the client or family is hostile or obnoxious, call the police
B. Carry the home health care agency identification in a purse or wallet
C. Visits can be scheduled at night with permission from the agency
D. Inform the agency of the times of the client’s scheduled visits
A. If the client or family is hostile or obnoxious, call the police
B. Carry the home health care agency identification in a purse or wallet
C. Visits can be scheduled at night with permission from the agency
D. Inform the agency of the times of the client’s scheduled visits
38. The home health nurse aide tells the home health nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the nurse’s best response?
A. “I am excited for you; he seems like a very nice young man.”
B. “You should not go out with him as long as she is a client of our agency.”
C. “I think you should tell the director of the home health care agency about this date.”
D. “You should never date someone you met while taking care of a client.”
A. “I am excited for you; he seems like a very nice young man.”
B. “You should not go out with him as long as she is a client of our agency.”
C. “I think you should tell the director of the home health care agency about this date.”
D. “You should never date someone you met while taking care of a client.”
39. The cardiac nurse is teaching the client diagnosed with CHF. Which teaching interventions should the nurse discuss with the client? *Select all that apply*
A. Notify the HCP if a client gains more than 2 lbs in one day
B. Keep the head of the bed elevated when sleeping
C. Take the loop diuretic once a day before going to sleep
D. Teach the client which foods are high in sodium and should be avoided
E. Perform isotonic exercises at least once a day
A. Notify the HCP if a client gains more than 2 lbs in one day
B. Keep the head of the bed elevated when sleeping
C. Take the loop diuretic once a day before going to sleep
D. Teach the client which foods are high in sodium and should be avoided
E. Perform isotonic exercises at least once a day
40. The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering?
A. warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time of 14 and an INR of 1.6
B. digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L
C. atenolol (Tenormin), a beta-blocker, for the client with an aspirate aminotransferase (AST) of 18 U/L
D. lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine level of 0.8 mg/dL
A. warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time of 14 and an INR of 1.6
B. digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L
C. atenolol (Tenormin), a beta-blocker, for the client with an aspirate aminotransferase (AST) of 18 U/L
D. lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine level of 0.8 mg/dL
41. The nurse is providing end-of-life care to a client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement?
A. Assess the client’s spiritual needs
B. Assess the client’s financial situation
C. Assess the client’s support system
D. Assess the client’s medical diagnosis
A. Assess the client’s spiritual needs
B. Assess the client’s financial situation
C. Assess the client’s support system
D. Assess the client’s medical diagnosis
42. The husband of the client diagnosed with infective endocarditis and who has a DNR tells the nurse, “My wife is not breathing.” Which intervention should the nurse implement first?
A. Contact the client’s HCP
B. Notify the rapid response team
C. Stay with the client and her husband
D. Instruct the UAP to perform post-mortem care
A. Contact the client’s HCP
B. Notify the rapid response team
C. Stay with the client and her husband
D. Instruct the UAP to perform post-mortem care
43. The hospice nurse is triaging phone calls from clients. Which client should the nurse call first?
A. The client whose family reports the client is not eating
B. The client who wants to rescind the out-of-hospital DNR
C. The client whose pain is not being controlled with the current medications
D. The client whose urinary incontinence has caused a Stage I pressure ulcer
A. The client whose family reports the client is not eating
B. The client who wants to rescind the out-of-hospital DNR
C. The client whose pain is not being controlled with the current medications
D. The client whose urinary incontinence has caused a Stage I pressure ulcer
44. The hospice nurse with working with a volunteer. Which task could the nurse delegate to the volunteer?
A. Sit with the client while he or she reminisces about life experiences
B. Give the client a sponge bath and rub lotion on bony prominences
C. Provide spiritual support for the client and family members
D. Check the home to see that all necessary medical equipment is available
A. Sit with the client while he or she reminisces about life experiences
B. Give the client a sponge bath and rub lotion on bony prominences
C. Provide spiritual support for the client and family members
D. Check the home to see that all necessary medical equipment is available
45. The nurse delegates post-mortem care to the UAP. The UAP tells the nurse she has never performed post-mortem care. Which statement is the best response by the nurse to the UAP?
A. “It can be uncomfortable. I will go with you and show you what to do.”
B. “The client is already dead. You cannot hurt him now.”
C. “There is nothing to it; it is just a bed bath and change of clothes.”
D. “Don’t worry. You can skip it this time but you need to learn what to do.”
A. “It can be uncomfortable. I will go with you and show you what to do.”
B. “The client is already dead. You cannot hurt him now.”
C. “There is nothing to it; it is just a bed bath and change of clothes.”
D. “Don’t worry. You can skip it this time but you need to learn what to do.”
46. The UAP tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP?
A. Call the HCP and report the client’s chest pain
B. Give a client some acetaminophen (Tylenol) while the nurse checks the client
C. Get the client’s medical records and bring them to the client’s room
D. Notify the client’s family of the onset of chest pain
A. Call the HCP and report the client’s chest pain
B. Give a client some acetaminophen (Tylenol) while the nurse checks the client
C. Get the client’s medical records and bring them to the client’s room
D. Notify the client’s family of the onset of chest pain
47. The RN and LPN are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN?
A. Feed the client who has an IV on both forearms
B. Assess the client diagnosed with stage IV heart failure
C. Discharge the client who had a cardiac catheterization
D. Administer the IVPB antibiotic cefriaxone (Rocephin)
A. Feed the client who has an IV on both forearms
B. Assess the client diagnosed with stage IV heart failure
C. Discharge the client who had a cardiac catheterization
D. Administer the IVPB antibiotic cefriaxone (Rocephin)
48. The hospice nurse is discussing the client’s care with the UAP. Which statement contains the best information about caring for a client with end-stage heart failure who is dying?
A. “Perform as much care for the client as possible to conserve his or her strength.”
B. “Do not get too attached to the client because it will hurt when he or she dies.”
C. “Be careful not to promise to withhold healthcare information from the team.”
D. “The client may want to talk about his or her life, but you should discourage that.”
A. “Perform as much care for the client as possible to conserve his or her strength.”
B. “Do not get too attached to the client because it will hurt when he or she dies.”
C. “Be careful not to promise to withhold healthcare information from the team.”
D. “The client may want to talk about his or her life, but you should discourage that.”
49. The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the UAP?
A. Have the UAP call the operator and announce the code
B. Tell the UAP to answer the other call lights on the unit
C. Send the UAP to the room to start rescue breaths
D. Ask the family to step out of the room during the code
A. Have the UAP call the operator and announce the code
B. Tell the UAP to answer the other call lights on the unit
C. Send the UAP to the room to start rescue breaths
D. Ask the family to step out of the room during the code
50. The family member of the client experiencing a cardiac arrest refuses to leave the client’s room. Which intervention should the administrative supervisor implement?
A. Stay with the family member and explain what the team is doing
B. Call hospital security to escort the family member out of the room
C. Ask the HCP whether the family member can stay
D. Ignore the family member unless she becomes hysterical
A. Stay with the family member and explain what the team is doing
B. Call hospital security to escort the family member out of the room
C. Ask the HCP whether the family member can stay
D. Ignore the family member unless she becomes hysterical
51. The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first?
A. Place the client on a telemetry monitor and assess the client
B. Call an ambulance to transfer the client to a charity hospital
C. Have the client sign a form agreeing to pay the bill
D. Ask the client why he chose to come to this hospital
A. Place the client on a telemetry monitor and assess the client
B. Call an ambulance to transfer the client to a charity hospital
C. Have the client sign a form agreeing to pay the bill
D. Ask the client why he chose to come to this hospital
52. The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first?
A. The client diagnosed with angina who is reporting chest pain
B. The client diagnosed with CHF who has bilateral 4+ peripheral edema
C. The client diagnosed with endocarditis who has a temperature of 100F
D. The client diagnosed with aortic valve stenosis who has syncope
A. The client diagnosed with angina who is reporting chest pain
B. The client diagnosed with CHF who has bilateral 4+ peripheral edema
C. The client diagnosed with endocarditis who has a temperature of 100F
D. The client diagnosed with aortic valve stenosis who has syncope
53. Which medication should the nurse administer first after receiving the morning shift report?
A. The IVPB antibiotic to the client with endocarditis admitted at 0530 today
B. The anti-platelet medication to the client who had a MI
C. The coronary vasodilator patch to the client with CAD
D. The statin medication to the client diagnosed with atherosclerosis
A. The IVPB antibiotic to the client with endocarditis admitted at 0530 today
B. The anti-platelet medication to the client who had a MI
C. The coronary vasodilator patch to the client with CAD
D. The statin medication to the client diagnosed with atherosclerosis
54. The nurse in a critical care cardiac unit is administering medications to a client. Which intervention should the nurse implement first?
A. Check the radial pulse before administering digoxin, a cardiac glycoside
B. Monitor the amiodorone level for the client receiving amiodorone
C. Obtain the latest PTT results on the client with the heparin drip
D. Check the liver function panel for the client receiving a dopamine drip
A. Check the radial pulse before administering digoxin, a cardiac glycoside
B. Monitor the amiodorone level for the client receiving amiodorone
C. Obtain the latest PTT results on the client with the heparin drip
D. Check the liver function panel for the client receiving a dopamine drip
55. The surgical nurse is admitting a client having heart surgery to the operating room. Which information would require the nurse to call a time-out?
A. The client is drowsy from the preoperative medication and drifts off to sleep
B. The consent form states mitral valve replacement and the client states aortic valve replacement
C. The chart and client’s armband states the client is allergic to the narcotic analgesic morphine
D. The client states his or her name and birth date as it appears on the chart
A. The client is drowsy from the preoperative medication and drifts off to sleep
B. The consent form states mitral valve replacement and the client states aortic valve replacement
C. The chart and client’s armband states the client is allergic to the narcotic analgesic morphine
D. The client states his or her name and birth date as it appears on the chart
56. The nurse is administering medication at 1800 to a client and uses the following MAR. Which intervention should the nurse implement first?
–Digoxin 0.125mg PO daily
–Furosemide 40mg IVP daily
–Cephalosporin 1800 500mg PO Q6H
–Warfarin 5mg PO daily
A. Assess the client’s potassium and digoxin levels
B. Monitor the client’s partial thromboplastin level
C. Check the client’s INR
D. Verify the client’s name and ID number with the MAR
–Digoxin 0.125mg PO daily
–Furosemide 40mg IVP daily
–Cephalosporin 1800 500mg PO Q6H
–Warfarin 5mg PO daily
A. Assess the client’s potassium and digoxin levels
B. Monitor the client’s partial thromboplastin level
C. Check the client’s INR
D. Verify the client’s name and ID number with the MAR
57. The nurse is administering medications to clients on a cardiac unit. Which medication should the nurse question administering?
A. The loop diuretic furosemide (Lasix) to a client who had a 320mL output in 4 hours
B. The anticoagulant enoxaparin (Lovenox) to a client who had open-heart surgery
C. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery
D. The ACE inhibitor captopril (Capoten) to a client who has a bp of 100/68
A. The loop diuretic furosemide (Lasix) to a client who had a 320mL output in 4 hours
B. The anticoagulant enoxaparin (Lovenox) to a client who had open-heart surgery
C. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery
D. The ACE inhibitor captopril (Capoten) to a client who has a bp of 100/68
58. The intensive care unit nurse and a UAP are caring for a client who has had a CABG. Which nursing task should the nurse assign to the UAP?
A. Monitor the client’s ABGs
B. Re-infuse the client’s blood using the cell saver
C. Assist the client to take a sponge bath
D. Change the client’s saturated leg dressing
A. Monitor the client’s ABGs
B. Re-infuse the client’s blood using the cell saver
C. Assist the client to take a sponge bath
D. Change the client’s saturated leg dressing
59. The nurse is preparing to administer two units of PRBCs to a client diagnosed with CHF. Which HCP order should the nurse question?
A. Administer each unit over 2 hours
B. Administer the loop diuretic furosemide (Lasix) IVP once
C. Restrict the client’s fluids to 1000mL per 24 hours
D. Have a CBC done the following morning
A. Administer each unit over 2 hours
B. Administer the loop diuretic furosemide (Lasix) IVP once
C. Restrict the client’s fluids to 1000mL per 24 hours
D. Have a CBC done the following morning
60. The elderly client on the cardiac unit was found on the floor by the bed. Which information should the nurse document in the client’s chart?
A. Fell. No injuries notes. Incident report completed. HCP notified.
B. Found on floor. No complaints of pain. Able to move all extremities
C. States no one answered the call light, so attempted to get up without help
D. Get out of bed without assistance and fell by the bedside
A. Fell. No injuries notes. Incident report completed. HCP notified.
B. Found on floor. No complaints of pain. Able to move all extremities
C. States no one answered the call light, so attempted to get up without help
D. Get out of bed without assistance and fell by the bedside
61. The home health nurse is caring for an elderly client. Which nursing task should the nurse delegate to the home health aide?
A. Cook and freeze meals for the client
B. Assist the client to sit on the front porch
C. Take the client for outings to the store
D. Monitor the client’s mental status
A. Cook and freeze meals for the client
B. Assist the client to sit on the front porch
C. Take the client for outings to the store
D. Monitor the client’s mental status
62. The client admitted to rule out a MI is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement?
A. Take the client’s pulse, respirations, and blood pressure
B. Call for a stat electrocardiogram and a troponin level
C. Place sublingual nitroglycerin 1/150g under the tongue
D. Notify the HCP that the client has pain
A. Take the client’s pulse, respirations, and blood pressure
B. Call for a stat electrocardiogram and a troponin level
C. Place sublingual nitroglycerin 1/150g under the tongue
D. Notify the HCP that the client has pain
63. We have an expert-written solution to this problem!
The client on the cardiac unit has a cardiac arrest. Which is the administrative supervisor nurse’s first intervention during the code?
A. Begin to take note to document the code
B. Make sure all the jobs are being done
C. Arrange for an ICU bed
D. Administer the emergency medications
A. Begin to take note to document the code
B. Make sure all the jobs are being done
C. Arrange for an ICU bed
D. Administer the emergency medications
64. Which client should the cardiac nurse assess first after receiving the p.m. shift report?
A. The client who is completing the second unit of PRBCs
B. The client who is crying after being informed of a terminal diagnosis
C. The client who refused to eat the dietary tray but got food from home
D. The client who became short of breath ambulating in the hallway
A. The client who is completing the second unit of PRBCs
B. The client who is crying after being informed of a terminal diagnosis
C. The client who refused to eat the dietary tray but got food from home
D. The client who became short of breath ambulating in the hallway
65. The nurse is caring for Mr. A.B., a client on a telemetry unit. At 0830 the client complains of chest pain. Which medication should the nurse administer?
–Morphine sulfate 2mg IVP QH PRN chest pain
–Oxycodone 7.5/acetaminophen 325mg PO Q4H PRN pain
–Maalox 30ml PO PRN indigestion
–Nitroglycerin 0.4mg SL Q5min up to 3 tablets PRN chest pain
–Nitroglycerin transdermal cream 1/2 inch
A. Administer 1/2 inch of nitroglycerin transdermally now
B. Morphine sulfate 2mg IVP STAT
C. Oxycodone 7.5mg/acetaminophen 325mg PO now
D. Nitroglycerin 0.4mg SL STAT
–Morphine sulfate 2mg IVP QH PRN chest pain
–Oxycodone 7.5/acetaminophen 325mg PO Q4H PRN pain
–Maalox 30ml PO PRN indigestion
–Nitroglycerin 0.4mg SL Q5min up to 3 tablets PRN chest pain
–Nitroglycerin transdermal cream 1/2 inch
A. Administer 1/2 inch of nitroglycerin transdermally now
B. Morphine sulfate 2mg IVP STAT
C. Oxycodone 7.5mg/acetaminophen 325mg PO now
D. Nitroglycerin 0.4mg SL STAT
66. The charge nurse on a cardiac unit has received lab results to assess. Which lab report is priority for the charge nurse to assess?
A. Ms. C.T., who is on a heparin drip
—aPT 15
—INR 1.4
—aPTT 56
B. Mr. R.S., who is scheduled for a CABG this morning
—aPT 11
—INR 1.0
—aPTT 34
—WBC 5.9
—RBC 4.9
—Hgb 13.5
—Hct 44.2
—Plt 292
C. Ms. T.R., who had a cardiac cauterization 18 hours ago.
—aPT 12
—INR 1.0
—aPTT 29
D. Mr. J.E., who was admitted to rule out gallbladder disease
— aPT 9.8
—INR 1.3
—aPTT 26
—Plt 392
A. Ms. C.T., who is on a heparin drip
—aPT 15
—INR 1.4
—aPTT 56
B. Mr. R.S., who is scheduled for a CABG this morning
—aPT 11
—INR 1.0
—aPTT 34
—WBC 5.9
—RBC 4.9
—Hgb 13.5
—Hct 44.2
—Plt 292
C. Ms. T.R., who had a cardiac cauterization 18 hours ago.
—aPT 12
—INR 1.0
—aPTT 29
D. Mr. J.E., who was admitted to rule out gallbladder disease
— aPT 9.8
—INR 1.3
—aPTT 26
—Plt 392
67. The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority
A. The 45 y/o client who complained of having chest pain at midnight last night and received NTG sublingually
B. The 62 y/o client who is complaining that no one answered the call light for 2 hours yesterday
C. The 29 y/o client diagnosed with septicemia who called to request more blankets because of being cold
D. Thee 78 y/o client diagnosed with dementia whose daughter is concerned because the client is more confused today
E. The 37 y/o client who has stage IV pressure sore and the dressing needs to be changed this morning
A. The 45 y/o client who complained of having chest pain at midnight last night and received NTG sublingually
B. The 62 y/o client who is complaining that no one answered the call light for 2 hours yesterday
C. The 29 y/o client diagnosed with septicemia who called to request more blankets because of being cold
D. Thee 78 y/o client diagnosed with dementia whose daughter is concerned because the client is more confused today
E. The 37 y/o client who has stage IV pressure sore and the dressing needs to be changed this morning
68. While ambulating in the hallway with the nurse, the client diagnosed with MI complains of chest pain. Which intervention should the nurse implement? *Select all that apply*
A. Administer nitroglycerin 0.4mg sublingual STAT
B. Have the client walk back to the room
C. Take the client’s vital signs
D. Place the client on supplemental oxygen
E. Ask the ward secretary to call the HCP for orders
A. Administer nitroglycerin 0.4mg sublingual STAT
B. Have the client walk back to the room
C. Take the client’s vital signs
D. Place the client on supplemental oxygen
E. Ask the ward secretary to call the HCP for orders
69. The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client’s drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25,000 units in 500mL of fluid. The current rate of infusion is 26mL per hour. At what rate should the nurse set the pump?
