1. The nurse is reviewing an electrocardiogram rhythm strip.

The P waves and

QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes
measure 0.06 second. The overall heart rate is 64 beats/minute. Which would
be a correct interpretation based on these characteristics?
a. Sinus bradycardia
b. Sick sinus syndrome
c. Normal sinus rhythm
d. First-degree heart block

Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60

to 100 beats/minute. The PR and QRS measurements are normal, measuring
0.12 to 0.20 second and 0.04 to 0.10 second, respectively.
2. A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. A nurse sees no electrocardiographic complexes on the screen. Which is
the priority action of the nurse?
a. Call a code.
b. Call the health care provider.
c. Check the client's status and lead placement.
d. Press the recorder button on the electrocardiogram console.
Sudden loss of electrocardiographic complexes indicates ventricular
asystole or possibly electrode displacement. Accurate assessment of
the client and equipment is necessary to determine the cause and
identify the appropriate intervention. The remaining options are
secondary to client assessment.
3. A client is having frequent premature ventricular contractions. The nurse
should place priority on assessment of which item?
a. Sensation of palpitations
b. Causative factors, such as caffeine
c. Precipitating factors, such as infection
d. Blood pressure and oxygen saturation
Premature ventricular contractions can cause hemodynamic
compromise. Therefore, the priority is to monitor the blood
pressure and oxygen saturation. The shortened ventricular filling
time can lead to decreased cardiac output. The client may be
asymptomatic or may feel palpitations. Premature ventricular
contractions can be caused by cardiac disorders, states of
hypoxemia, or by any number of physiological stressors, such as
infection, illness, surgery, or trauma, and by intake of caffeine,
nicotine, or alcohol.
4. The nurse is evaluating a client's response to cardioversion. Which observation
would be of highest priority to the nurse?
a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness
Nursing responsibilities after cardioversion include maintenance
first of a patent airway, and then oxygen administration, assessment
of vital signs and level of consciousness, and dysrhythmia detection.
5. A client's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08
second, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
a. Sinus dysrhythmia
b. Sinus tachycardia
c. Sinus bradycardia
d. Normal sinus rhythm
Sinus tachycardia has the characteristics of normal sinus rhythm,
including a regular PP interval and normal-width PR and QRS
intervals; however, the rate is the differentiating factor. In sinus
tachycardia, the atrial and ventricular rates are greater than 100
beats/minute.
6. The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. How should the nurse correctly
interpret the client's neurovascular status?
a. The neurovascular status is normal because of increased blood
flow through the leg.
b. The neurovascular status is moderately impaired, and the surgeon should be
called.
c. The neurovascular status is slightly deteriorating and should be monitored for
another hour.
d. The neurovascular status is adequate from an arterial approach, but venous
complications are arising.
An expected outcome of aortoiliac bypass graft surgery is warmth,
redness, and edema in the surgical extremity because of increased
blood flow. The remaining options are incorrect interpretations.
7. The nurse is evaluating the condition of a client after pericardiocentesis
performed to treat cardiac tamponade. Which observation would indicate that
the procedure was unsuccessful?
a. Rising blood pressure
b. Clearly audible heart sounds
c. Client expressions of relief
d. Rising central venous pressure
Following pericardiocentesis, a rise in blood pressure and a fall in
central venous pressure are expected. The client usually expresses
immediate relief. Heart sounds are no longer muffled or distant.
8. A client with angina complains that the anginal pain is prolonged and severe
and occurs at the same time each day, most often at rest in the absence of
precipitating factors. How would the nurse best describe this type of anginal
pain?
a. Stable angina
b. Variant angina
c. Unstable angina
d. Nonanginal pain
Variant angina, or Prinzmetal's angina, is prolonged and severe and
occurs at the same time each day, most often at rest. Stable angina is
 induced by exercise and relieved by rest or nitroglycerin tablets.
Unstable angina occurs at lower levels of activity or at rest, is less
predictable, and is often a precursor of myocardial infarction.
9. The nurse is monitoring a client with acute pericarditis for signs of cardiac
tamponade. Which assessment finding indicates the presence of this
complication?
a. Flat neck veins
b. A pulse rate of 60 beats/min
c. Muffled or distant heart sounds
d. Wheezing on auscultation of the lungs
Assessment findings associated with cardiac tamponade include
tachycardia, distant or muffled heart sounds, jugular vein distention
with clear lung sounds, and a falling blood pressure accompanied by
pulsus paradoxus (a drop in inspiratory blood pressure greater than
10 mm Hg). Bradycardia is not a sign of cardiac tamponade.
10. The home care nurse is providing instructions to a client with an arterial
ischemic leg ulcer about home care management and self-care management.
Which statement, if made by the client, indicates a need for further instruction?
a. "I need to be sure not to go barefoot around the house."
b. “If I cut my toenails, I need to be sure that I cut them straight across."
c. "It is all right to apply lanolin to my feet, but I shouldn't place it between my
toes."
d. "I need to be sure that I elevate my leg above my heart level for at
least an hour every day."
Foot care instructions for the client with peripheral arterial disease
are the same as those for a client with diabetes mellitus. The client
with arterial disease, however, should avoid raising the legs above
the level of the heart unless instructed to do so as part of an exercise
program or if venous stasis is also present. The client statements in
options 1, 2, and 3 are correct statements.
11. The nurse is providing instructions to a client with a diagnosis of hypertension
regarding high-sodium items to be avoided. The nurse instructs the client to
avoid consuming which item?
a. Bananas
b. Broccoli
c. Antacids
d. Cantaloupe
The sodium level can increase with the use of several types of
products, including toothpaste and mouthwash; over-the-counter
medications such as analgesics, antacids, laxatives, and sedatives;
and softened water and mineral water. Clients are instructed to read
labels for sodium content. Water that is bottled, distilled, deionized,
or demineralized may be used for drinking and cooking. Fresh fruits
and vegetables are low in sodium.
12. The nurse is preparing discharge instructions for a client with Raynaud's
disease. The nurse should plan to provide which instruction to the client?
a. Use nail polish to protect the nail beds from injury.
b. Stop smoking because it causes cutaneous vasospasm.
c. Wear gloves for all activities involving use of both hands.
 d. Always wear warm clothing even in warm climates to prevent
vasoconstriction.
13. The nurse is developing a plan of care for a client with varicose veins in whom
skin breakdown occurred over the varicosities as a result of secondary infection.
Which is a priority intervention?
a. Keep the legs aligned with the heart.
b. Elevate the legs higher than the heart.
c. Clean the skin with alcohol every hour.
d. Position the client onto the side every shift.
In the client with a venous disorder, the legs are elevated above the
level of the heart to assist with the return of venous blood to the
heart. Alcohol is very irritating and drying to tissues and should not
be used in areas of skin breakdown. Option 4 specifies infrequent
care intervals, so it is not the priority intervention. 
14. The nurse in the medical unit is reviewing the laboratory test results for a client
who has been transferred from the intensive care unit. The nurse notes that a
cardiac troponin T level assay was performed while the client was in the
intensive care unit. The nurse determines that this test was performed to assist
in diagnosing which condition?
a. Heart failure
b. Atrial fibrillation
c. Myocardial infarction
d. Ventricular tachycardia
Cardiac troponin T or cardiac troponin I has been found to be a
protein marker in the detection of myocardial infarction, and assay
for this protein is used in some institutions to aid in the diagnosis of
a myocardial infarction. The test is not used to diagnose heart
failure, ventricular tachycardia, or atrial fibrillation.
15. The nurse is caring for a client with cardiac disease who has been placed on a
cardiac monitor. The nurse notes that the client has developed atrial fibrillation
and has a ventricular rate of 150 beats/min. The nurse should next assess the
client for which finding?
a. Hypotension
b. Flat neck veins
c. Complaints of nausea
d. Complaints of headache
The client with uncontrolled atrial fibrillation with a ventricular rate
greater than 100 beats/min is at risk for low cardiac output owing to
loss of atrial kick. The nurse assesses the client for palpitations,
chest pain or discomfort, hypotension, pulse deficit, fatigue,
weakness, dizziness, syncope, shortness of breath, and distended
neck veins.
16. The nurse is performing an assessment on a client with a diagnosis of left-sided
heart failure. Which assessment component would elicit specific information
regarding the client's left-sided heart function?
a. Listening to lung sounds
b. Monitoring for organomegaly
c. Assessing for jugular vein distention
d. Assessing for peripheral and sacral edema
 The client with heart failure may present with different symptoms,
depending on whether the right or the left side of the heart is failing.
Peripheral and sacral edema, jugular vein distention, and
organomegaly all are manifestations of problems with right-sided
heart function. Lung sounds constitute an accurate indicator of left-
sided heart function.
17. The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a
client with a diagnosis of myocardial infarction. The nurse notes that the PR
interval is 0.20 second. The nurse should make which interpretation about this
finding?
a. A normal finding
b. Indicative of atrial flutter
c. Indicative of atrial fibrillation
d. Indicative of impending reinfarction
The PR interval represents the time it takes for the cardiac impulse
to spread from the atria to the ventricles. The normal range for the
PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
18. The nurse in the medical unit is assigned to provide discharge teaching to a
client with a diagnosis of angina pectoris. The nurse is discussing lifestyle
changes that are needed to minimize the effects of the disease process. The
client continually changes the subject during the teaching session. The nurse
interprets that this client's behavior is most likely related to which problem?
a. Anxiety related to the need to make lifestyle changes
b. Boredom resulting from having already learned the material
c. An attempt to ignore or deny the need to make lifestyle changes
d. Lack of understanding of the material provided at the teaching session and
embarrassment about asking questions
Denial is a defense mechanism that allows the client to minimize a
threat that may be manifested by refusal to discuss what has
happened. Denial is a common early reaction associated with chest
discomfort, angina, or myocardial infarction (MI). Anxiety usually is
manifested by symptoms of sympathetic nervous system arousal. No
data are provided in the question that would lead the nurse to
interpret the client's behavior as boredom or as either
understanding or not understanding the material provided at the
teaching session.
19. A home care nurse is visiting a client to provide follow-up evaluation and care of
a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the
ulcer is pale and deep and that the surrounding tissue is cool to the touch. The
nurse should document that these findings identify which type of ulcer?
a. A stage 1 ulcer
b. A vascular ulcer
c. An arterial ulcer
d. A venous stasis ulcer
Arterial ulcers have a pale deep base and are surrounded by tissue
that is cool with trophic changes such as dry skin and loss of hair.
Arterial ulcers are caused by tissue ischemia from inadequate
arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a
reddened area with an intact skin surface. A venous stasis ulcer
 (vascular) has a dark red base and is surrounded by brown skin with
local edema. This type of ulcer is caused by the accumulation of
waste products of metabolism that are not cleared, as a result of
venous congestion. 
20. The nurse is developing a plan of care for a client who will be admitted to the
hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The
nurse develops the plan, expecting that the health care provider will most likely
prescribe which option?
a. Maintain bed rest.
b. Maintain the affected leg in a dependent position.
c. Administer an opioid analgesic every 4 hours around the clock.
d. Apply cool packs to the affected leg for 20 minutes every 4 hours.
Standard management for the client with DVT includes bed rest;
limb elevation; relief of discomfort with warm, moist heat; and
analgesics as needed. Ambulation is contraindicated because such
activity can cause the thrombus to dislodge and travel to the lungs.
Opioid analgesics are not required to relieve pain, and pain normally
is relieved with acetaminophen (Tylenol).
21. A client with a diagnosis of varicose veins is scheduled for treatment by
sclerotherapy and asks the nurse to describe the procedure. Which response
should the nurse make?
a. "It involves tying off the veins so that circulation is redirected in another
area."
b. "It involves surgically removing the varicosity, so anesthesia will be required."
c. "It involves tying off the veins to prevent sluggishness of blood from
occurring."
d. "It involves injecting an agent into the vein to damage the vein
wall and close it off."
Sclerotherapy is the injection of a sclerosing agent into a varicosity.
The agent damages the vessel and causes aseptic thrombosis, which
results in vein closure. With no blood flow through the vessel,
distention will not occur. The surgical procedure for varicose veins
is vein ligation and stripping. This procedure involves tying off the
varicose vein and large tributaries and then removing the vein with
the use of a hook and wires applied through multiple small incisions
in the leg. Other treatments include the application of
radiofrequency (RF) energy, in which the vein is heated from the
inside by the RF energy and shrinks; collateral veins nearby take
over. Laser treatment is another alternative to surgery; in this
treatment a laser fiber is used to heat and close the main vessel that
is contributing to the varicosity.
22. A female client calls the nurse at the clinic and reports that ever since the vein
ligation and stripping procedure was performed, she has been experiencing a
sensation as though the affected leg is falling asleep. The nurse should make
which response to the client?
a. "Apply warm packs to the leg."
b. "Keep the leg elevated as much as possible."
c. "Contact your health care provider right away to report this
problem."
 d. "This normally occurs after surgery and will subside when the edema goes
down."
23. The nurse is caring for a client who has been hospitalized with a diagnosis of
angina pectoris. The client is receiving oxygen via nasal cannula at 2 L/min. The
client asks why the oxygen is necessary. The nurse should provide which
information to the client?
a. Oxygen has a calming effect.
b. Oxygen will prevent the development of any thrombus.
c. Oxygen dilates the blood vessels so that they can supply more nutrients to the
heart muscle.
d. The pain of angina pectoris occurs because of a decreased oxygen
supply to heart cells.
The pain associated with angina results from ischemia of myocardial
cells. The pain often is precipitated by activity that places more
oxygen demand on heart muscle. Supplemental oxygen will help to
meet the added demands on the heart muscle. Oxygen does not
dilate blood vessels or prevent thrombus formation and does not
directly calm the client.
24. A client with a diagnosis of angina pectoris is hospitalized for an angioplasty.
The client returns to the nursing unit after the procedure, and the nurse
provides instructions to the client regarding home care measures. Which
statement, if made by the client, indicates an understanding of the instructions?
a. "I need to cut down on cigarette smoking."
b. "I am so relieved that my heart is repaired."
c. "I need to adhere to my dietary restrictions."
d. "I am so relieved that I can eat anything I want to now."
After angioplasty, the client needs to be instructed regarding the
specific dietary restrictions that must be followed. Making the
recommended dietary and lifestyle changes will assist in preventing
further atherosclerosis. Abrupt closure of the artery can occur if the
dietary and lifestyle recommendations are not followed. Cigarette
smoking needs to be stopped. An angioplasty does not repair the
heart.
25. The nurse is caring for a client with a diagnosis of myocardial infarction (MI)
and is assisting the client in completing the diet menu. Which beverage should
the nurse instruct the client to select from the menu?
a. Tea
b. Cola
c. Coffee
d. Raspberry juice
A client with a diagnosis of MI should not consume caffeinated
beverages. Caffeinated products can produce a vasoconstrictive
effect, leading to further cardiac ischemia. Coffee, tea, and cola all
contain caffeine and need to be avoided in the client with MI.
26. The nurse is performing an admission assessment on a client with a diagnosis of
angina pectoris who takes nitroglycerin for chest pain at home. During the
assessment the client complains of chest pain. The nurse should immediately
ask the client which question?
a. "Where is the pain located?"
 b. "Are you having any nausea?"
c. "Are you allergic to any medications?"
d. "Do you have your nitroglycerin with you?"
If a client complains of chest pain, the initial assessment question
would be to ask the client about the pain intensity, location,
duration, and quality. Although options 2, 3, and 4 all may be
components of the assessment, none of these questions would be the
initial assessment question with this client.
27. The nurse has provided dietary instructions to a client with coronary artery
disease. Which statement by the client indicates an understanding of the dietary
instructions?
a. "I'll need to become a strict vegetarian."
b. "I should use polyunsaturated oils in my diet."
c. "I need to substitute eggs and whole milk for meat."
d. "I should eliminate all cholesterol and fat from my diet."
The client with coronary artery disease should avoid foods high in
saturated fat and cholesterol such as eggs, whole milk, and red meat.
These foods contribute to increases in low-density lipoproteins. The
use of polyunsaturated oils is recommended to control
hypercholesterolemia. It is not necessary to eliminate all cholesterol
and fat from the diet. It is not necessary to become a strict
vegetarian.
28. A client is admitted to the visiting nurse service for assessment and follow-up
after being discharged from the hospital with new-onset heart failure (HF). The
nurse teaches the client about the dietary restrictions required with HF. Which
statement by the client indicates that further teaching is needed?
a. "I'm not supposed to eat cold cuts."
b. "I can have most fresh fruits and vegetables."
c. "I'm going to weigh myself daily to be sure I don't gain too much fluid."
d. "I'm going to have a ham and cheese sandwich and potato chips
for lunch."
When a client has HF, the goal is to reduce fluid accumulation. One
way that this is accomplished is through sodium reduction. Ham
(and most cold cuts), cheese, and potato chips are high in sodium.
Daily weighing is an appropriate intervention to help the client
monitor fluid overload. Most fresh fruits and vegetables are low in
sodium.
29. The nurse is performing a health screening on a 54-year-old client. The client
has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL, and
fasting blood glucose level of 184 mg/dL. The nurse interprets this to mean that
the client has which modifiable risk factor for coronary artery disease (CAD)?
a. Age
b. Hypertension
c. Hyperlipidemia
d. Glucose intolerance
Hypertension, cigarette smoking, and hyperlipidemia are modifiable
risk factors that are predictors of CAD. Glucose intolerance, obesity,
and response to stress are contributing modifiable risk factors to
CAD. Age greater than 40 years is a nonmodifiable risk factor. The
 nurse places priority on risk factors that can be modified. In this
scenario, the abnormal value is the fasting blood glucose level,
indicating glucose intolerance as the priority risk factor.
30. The nurse is trying to determine the ability of the client with myocardial
infarction (MI) to manage independently at home after discharge. Which
statement by the client is the strongest indicator of the potential for difficulty
after discharge?
a. "I need to start exercising more to improve my health."
b. "I will be sure to keep my appointment with the cardiologist."
c. "I don't have anyone to help me with doing heavy housework at
home."
d. "I think I have a good understanding of what all my medications are for."
To ensure the best outcome, clients should be able to comply with
instructions related to activity, diet, medications, and follow-up
health care on discharge from the hospital after an MI. All of the
options except the correct option indicate that the client will be
successful in these areas.
31. The home care nurse has taught a client with a problem of inadequate cardiac
output about helpful lifestyle adaptations to promote health. Which statement
by the client best demonstrates an understanding of the information provided?
a. "I will eat enough daily fiber to prevent straining at stool."
b. "I will try to exercise vigorously to strengthen my heart muscle."
c. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney
function."
d. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging
blood vessels."
Standard home care instructions for a client with this problem
include, among others, lifestyle changes such as decreased alcohol
intake, avoiding activities that increase the demands on the heart,
instituting a bowel regimen to prevent straining and constipation,
and maintaining fluid and electrolyte balance. Consuming 3000 to
3500 mL of fluid and exercising vigorously will increase the cardiac
workload.
32. A client has been experiencing difficulty with completion of daily activities
because of underlying cardiovascular disease, as evidenced by exertional fatigue
and increased blood pressure. Which observation by the nurse best indicates
client progress in meeting goals for this problem?
a. Ambulates 10 feet farther each day
b. Verbalizes the benefits of increasing activity
c. Chooses a healthy diet that meets caloric needs
d. Sleeps without awakening throughout the night
Each of the options indicates a positive outcome on the part of the
client. Both options 2 and the correct one relate to the client
problem of difficulty with completion of daily activities. However,
the question asks about progress. The correct option is more action-
oriented and therefore is the better choice. Option 3 would most
likely indicate progress if the client had a problem of inadequate
nutritional intake. Option 4 would be a satisfactory outcome for a
client experiencing difficulty sleeping.
33. The health care provider has written a prescription for a client to have an
echocardiogram. Which action should the nurse take to prepare the client for
the procedure?
a. Questions the client about allergies to iodine or shellfish
b. Has the client sign an informed consent form for an invasive procedure
c. Tells the client that the procedure is painless and takes 30 to 60
minutes
d. Keeps the client on nothing-by-mouth (NPO) status for 2 hours before the
procedure
34. A client with coronary artery disease is scheduled to have a diagnostic exercise
stress test. Which instruction should the nurse plan to provide to the client
about this procedure?
a. Eat breakfast just before the procedure.
b. Wear firm, rigid shoes, such as workboots.
c. Wear loose clothing with a shirt that buttons in front.
d. Avoid cigarettes for 30 minutes before the procedure.
The client should wear loose, comfortable clothing for the
procedure. Electrocardiogram (ECG) lead placement is enhanced if
the client wears a shirt that buttons in the front. The client should
receive nothing by mouth after bedtime or for a minimum of 2 hours
before the test. The client should wear rubber-soled, supportive
shoes, such as athletic training shoes. The client should avoid
smoking, alcohol, and caffeine on the day of the test. Inadequate or
incorrect preparation can interfere with the test, with the potential
for a false-positive result.
35. A client is scheduled for a cardiac catheterization to diagnose the extent of
coronary artery disease. The nurse places highest priority on telling the client to
report which sensation during the procedure?
a. Chest pain
b. Urge to cough
c. Warm, flushed feeling
d. Pressure at the insertion site
The client is taught to report chest pain or any unusual sensations
immediately. The client also is told that he or she may be asked to
cough or breathe deeply from time to time during the procedure.
The client is informed that a warm, flushed feeling may accompany
dye injection and is normal. Because a local anesthetic is used, the
client is expected to feel pressure at the insertion site.
36. A client recovering from pulmonary edema is preparing for discharge. What
should the nurse plan to teach the client to do to manage or prevent recurrent
symptoms after discharge?
a. Sleep with the head of bed flat.
b. Weigh himself or herself on a daily basis.
c. Take a double dose of the diuretic if peripheral edema is noted.
d. Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.
The client can best determine fluid status at home by weighing
himself or herself on a daily basis. Increases of 2 to 3 lb in a short
period are reported to the health care provider (HCP). The client
should sleep with the head of the bed elevated. During recumbent
 sleep, fluid (which has seeped into the interstitium with the
assistance of the effects of gravity) is rapidly reabsorbed into the
systemic circulation. Sleeping with the head of the bed flat is
therefore avoided. The client does not modify medication dosages
without consulting the HCP.
37. A client is scheduled to undergo cardiac catheterization for the first time, and
the nurse provides instructions to the client. Which client statement indicates
an understanding of the instructions?
a. "It will really hurt when the catheter is first put in."
b. "I will receive general anesthesia for the procedure."
c. "I will have to go to the operating room for this procedure."
d. "I probably will feel tired after the test from lying on a hard x-ray
table for a few hours."
It is common for the client to feel fatigued after the cardiac
catheterization procedure. A local anesthetic is used, so little to no
pain is experienced with catheter insertion. General anesthesia is
not used. Other preprocedure teaching points include the fact that
the procedure is done in a darkened cardiac catheterization room.
The x-ray table is hard and may be tilted periodically, and the
procedure may take 1 to 2 hours. The client may feel various
sensations with catheter passage and dye injection.
38. A client admitted to the hospital with coronary artery disease complains of
dyspnea at rest. The nurse caring for the client uses which item as the best
means to monitor respiratory status on an ongoing basis?
a. Apnea monitor
b. Oxygen flowmeter
c. Telemetry cardiac monitor
d. Oxygen saturation monitor
Dyspnea in the cardiac client often is accompanied by hypoxemia.
Hypoxemia can be detected by an oxygen saturation monitor,
especially if it is used continuously. An apnea monitor detects apnea
episodes, such as when the client has stopped breathing briefly. An
oxygen flowmeter is part of the setup for delivering oxygen therapy.
Cardiac monitors detect dysrhythmias. 
39. A client with a history of angina pectoris tells the nurse that chest pain usually
occurs after going up two flights of stairs or after walking four blocks. What type
of angina should the nurse determine that the client is experiencing?
a. Stable
b. Variant
c. Unstable
d. Intractable
Stable angina is triggered by a predictable amount of effort or
emotion. Variant angina is triggered by coronary artery spasm; the
attacks are of longer duration than in classic angina and tend to
occur early in the day and at rest. Unstable angina is triggered by an
unpredictable amount of exertion or emotion and may occur at
night; the attacks increase in number, duration, and severity over
time. Intractable angina is chronic and incapacitating and is
refractory to medical therapy.
40. A client with a first-degree heart block has an electrocardiogram (ECG) taken
during an episode of chest pain. The nurse knows that which ECG finding would
be an indication of first-degree heart block?
a. Presence of Q waves
b. Tall, peaked T waves
c. Prolonged PR interval
d. Widened QRS complex
A prolonged PR interval indicates first-degree heart block. The
development of Q waves indicates myocardial necrosis. Tall, peaked
T waves may indicate hyperkalemia. A widened QRS complex
indicates a delay in intraventricular conduction, such as bundle
branch block. An ECG taken during a pain episode is intended to
capture ischemic changes, which also include ST-segment elevation
or depression.
41. The nurse is teaching the client with angina pectoris about disease management
and lifestyle changes that are necessary to control disease progression. Which
statement by the client indicates a need for further teaching?
a. "I will avoid using table salt with meals."
b. "It is best to exercise once a week for 1 hour."
c. "I will take nitroglycerin whenever chest discomfort begins."
d. "I will use muscle relaxation to cope with stressful situations."
Exercise is most effective when done at least 3 times a week for 20 to
30 minutes to reach a target heart rate. Other healthful habits
include limiting salt and fat in the diet and using stress management
techniques. The client also should be taught to take nitroglycerin
before any activity that previously caused the pain and to take the
medication at the first sign of chest discomfort.
42. The ambulatory care nurse is working with a client who has been diagnosed
with Prinzmetal's (variant) angina. What should the nurse plan to teach the
client about this type of angina?
a. It is most effectively managed by β-blocking agents.
b. It has the same risk factors as stable and unstable angina.
c. It can be controlled with a low-sodium, high-potassium diet.
d. Generally it is treated with calcium-channel-blocking agents
Prinzmetal's angina results from spasm of the coronary vessels and
is treated with calcium-channel blockers. β-Blockers are
contraindicated because they may actually worsen the spasm. The
risk factors are unknown, and this type of angina is relatively
unresponsive to nitrates. Diet therapy is not specifically indicated.
43. The nurse working in a long-term care facility is assessing a client who is
experiencing chest pain. The nurse should interpret that the pain is most likely
caused by myocardial infarction (MI) on the basis of what assessment finding?
a. The client is not experiencing dyspnea.
b. The client is not experiencing nausea or vomiting.
c. The pain has not been relieved by rest and nitroglycerin tablets.
d. The client says the pain began while she was trying to open a stuck dresser
drawer.
The pain of MI is not relieved by rest and nitroglycerin and requires
opioid analgesics, such as morphine sulfate, for relief. The pain of
 angina may radiate to the left shoulder, arm, neck, or jaw. It often is
precipitated by exertion or stress, is accompanied by few associated
symptoms, and is relieved by rest and nitroglycerin. The pain of MI
also may radiate to the left arm, shoulder, jaw, and neck. It typically
begins spontaneously, lasts longer than 30 minutes, and frequently
is accompanied by associated symptoms (such as nausea, vomiting,
dyspnea, diaphoresis, or anxiety). 
44. A client with myocardial infarction (MI) has been transferred from the coronary
care unit (CCU) to the general medical unit. What activity level should the nurse
encourage for the client immediately after transfer?
a. Ad lib activities as tolerated
b. Strict bed rest for 24 hours after transfer
c. Bathroom privileges and self-care activities
d. Unsupervised hallway ambulation for distances up to 200 feet
On transfer from CCU to an intermediate care or general medical
unit, the client is allowed self-care activities and bathroom
privileges. Activities ad lib as tolerated is premature at this time and
potentially harmful for this client. It is unnecessary and possibly
harmful to limit the client to bed rest. The client should ambulate
with supervision in the hall for brief distances, with the distances
being gradually increased to 50, 100, and 200 feet.
45. A client with no history of heart disease has experienced acute myocardial
infarction and has been given thrombolytic therapy with tissue plasminogen
activator. What assessment finding should the nurse identify as the most likely
indicator that the client is experiencing complications of this therapy?
a. Tarry stools
b. Nausea and vomiting
c. Orange-colored urine
d. Decreased urine output
Thrombolytic agents are used to dissolve existing thrombi, and the
nurse should monitor the client for obvious or occult signs of
bleeding. This includes assessment for obvious bleeding within the
gastrointestinal (GI) tract, urinary system, and skin. It also includes
Hematest testing of secretions for occult blood. The correct option is
the only one that indicates the presence of blood.
46. The nurse is discussing smoking cessation with a client diagnosed with coronary
artery disease (CAD). Which statement should the nurse make to try to motivate
the client to quit smoking?
a. "None of the cardiovascular effects are reversible, but quitting might prevent
lung cancer."
b. "Because most of the damage has already been done, it will be all right to cut
down a little at a time."
c. "If you totally quit smoking right now, you can cut your cardiovascular risk to
zero within a year."
d. "If you quit now, your risk of cardiovascular disease will decrease
to that of a nonsmoker in 3 to 4 years."
The risks to the cardiovascular system from smoking are
noncumulative and are not permanent. Three to 4 years after
cessation, a client's cardiovascular risk is similar to that of a person
 who never smoked. In addition, tobacco use and passive smoking
from "secondhand smoke" (also called environmental smoke)
substantially reduce blood flow in the coronary arteries. Options 1,
2, and 3 are incorrect.
47. A client has experienced an episode of pulmonary edema. The nurse determines
that the client's respiratory status is improving after this episode if which breath
sounds are noted?
a. Rhonchi
b. Wheezes
c. Crackles in the bases
d. Crackles throughout the lung fields
Pulmonary edema is characterized by extreme breathlessness,
dyspnea, air hunger, and the production of frothy, pink-tinged
sputum. As the client's condition improves, the amount of fluid in
the alveoli decreases, which may be detected by crackles in the
bases. (Clear lung sounds indicate full resolution of the episode.)
Rhonchi and wheezes are not associated with pulmonary edema.
Auscultation of the lungs reveals crackles throughout the lung
fields. 
48. A hospitalized client has been diagnosed with heart failure as a complication of
hypertension. In explaining the disease process to the client, the nurse identifies
which chamber of the heart as primarily responsible for the symptoms?
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
Hypertension increases the workload of the left ventricle because
the ventricle has to pump the stroke volume against increased
resistance (afterload) in the major blood vessels. Over time this
causes the left ventricle to fail, leading to signs and symptoms of
heart failure. Options 1, 2, and 4 are not the chambers that are
primarily responsible for this disease process although these
chambers may become affected as the disease becomes more
chronic.
49. A client has experienced a myocardial infarction. The nurse plans care for the
client, knowing that the person's chest pain is caused by tissue hypoxia in which
layer of the heart?
a. Myocardium
b. Endocardium
c. Parietal pericardium
d. Visceral pericardium
The myocardial layer of the heart is damaged when a client
experiences a myocardial infarction. This is the middle layer that
contains the striated muscle fibers responsible for the contractile
force of the heart. The endocardium is the thin inner layer of cardiac
tissue. The parietal pericardium and visceral pericardium are outer
layers that protect the heart from injury and infection.
50. A client admitted to the hospital with chest pain and a history of type 2 diabetes
mellitus is scheduled for cardiac catheterization. Which medication would need
 to be withheld for 24 hours before the procedure and for 48 hours after the
procedure?
a. Regular insulin
b. Glipizide (Glucotrol)
c. Repaglinide (Prandin)
d. Metformin (Glucophage)
Metformin (Glucophage) needs to be withheld 24 hours before and
for 48 hours after cardiac catheterization because of the injection of
contrast medium during the procedure. If the contrast medium
affects kidney function, with metformin in the system, the client
would be at increased risk for lactic acidosis. The medications in the
remaining options do not need to be withheld 24 hours before and
48 hours after cardiac catheterization.
51.  You are working in the triage area of an ED, and four patients approach the triage desk at
the same time. List the order in which you will assess these patients.
a. An ambulatory, dazed 25-year-old male with a bandaged head wound
b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting

ANSWER B, A, D, C – An irritable infant with fever and petechiae should be further assessed
for other meningeal signs. The patient with the head wound needs additional history and
assessment for intracranial pressure. The patient with moderate abdominal pain is
uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be
delayed 24 – 48 hours if necessary.
52.  In conducting a primary survey on a trauma patient, which of the following is considered one
of the priority elements of the primary survey?
a. Complete set of vital signs
b. Palpation and auscultation of the abdomen
c. Brief neurologic assessment
d. Initiation of pulse oximetry

ANSWER C – A brief neurologic assessment to determine level of consciousness and pupil

reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation
of pulse oximetry are considered part of the secondary survey.
53. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness.
This patient should be prioritized into which category?
a. High urgent
b. Urgent
c. Non-urgent
d. Emergent
 ANSWER D – Chest pain is considered an emergent priority, which is defined as potentially
life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g.
kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not
commonly used; however, in 5-tier triage systems, High urgent patients fall between
emergent and urgent in terms of the time lapsing prior to treatment).
54. It is the summer season, and patients with signs and symptoms of heat-related illness
present in the emergency department. Which patient needs attention first?
a. An elderly person complains of dizziness and syncope after standing in the sun for several
hours to view a parade
b. A marathon runner complains of severe leg cramps and nausea. Tachycardia,
diaphoresis, pallor, and weakness are observed.
c. A previously healthy homemaker reports broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse diaphoresis are observed.
d. A homeless person, poor historian, presents with altered mental status, poor
muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.

ANSWER D – The homeless person has symptoms of heat stroke, a medical emergency,
which increases risk for brain damage. Elderly patients are at risk for
heat syncope and should be educated to rest in cool area and avoid future similar situations.
The runner is having heat crams, which can be managed with rest and fluids. The housewife
is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and
cooling measures. The prognosis for recovery is good.
55. The emergency medical service (EMS) has transported a patient with severe chest pain. As
the patient is being transferred to the emergency stretcher, you note unresponsiveness,
cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the
nursing assistant?
a. Chest compressions
b. Bag-valve mask ventilation
c. Assisting with oral intubation
d. Placing the defibrillator pads

ANSWER A – Nursing assistants are trained in basic cardiac life support and can perform
chest compressions. The use of the bag-valve mask requires practice and usually a
respiratory therapist will perform this function. The nurse or the respiratory therapist should
provide PRN assistance during intubation. The defibrillator pads are clearly marked;
however, placement should be done by the RN or physician because of the potential for skin
damage and electrical arcing.
56. An anxious 24-year-old college student complains of tingling sensations, palpitations, and
chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing
action should you take?
 a. Notify the physician immediately.
b. Administer supplemental oxygen.
c. Have the student breathe into a paper bag.
d. Obtain an order for an anxiolytic medication.

ANSWER C – The patient is hyperventilating secondary to anxiety, and breathing into a

paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will
help. Other treatments such as oxygen and medication may be needed if other causes are
identified.
57. An experienced traveling nurse has been assigned to work in the emergency department;
however, this is the nurse’s first week on the job. Which area of the emergency department
is the most appropriate assignment for the nurse?
a. Trauma team
b. Triage
c. Ambulatory or fast track clinic
d. Pediatric medicine team

 ANSWER C – The fast track clinic will deal with relatively stable patients. Triage, trauma,
and pediatric medicine should be staffed with experienced nurses who know the hospital
routines and policies and can rapidly locate equipment.
58. A 36-year-old patient with a history of seizures and medication compliance of phenytoin
(Dilantin) and carbamazepine (Tegretol) is brought to the emergency department by the MS
personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate
that the physician will order which drug for status epilepticus?
a. PO phenytoin and carbamazepine
b. IV lorazepam (Ativan)
c. IV carbamazepam
d. IV magnesium sulfate

ANSWER B – IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is
used in the management of generalized tonic-clonic, absence or mixed type seizures, but it
does not come in an IV form. PO (per os) medications are inappropriate for this emergency
situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
59. You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What
information should you immediately report to the physician?
a. The parent is unsure about the child’s tetanus immunization status.
b. The child is upset and pulls out the IV.
c. The parent declines the IV conscious sedation.
d. The parent wants information about the IV conscious sedation.
 ANSWER C – Parent refusal is an absolute contraindication; therefore, the physician must
be notified. Tetanus status can be addressed later. The RN can
restart the IV and provide information about conscious sedation; if the parent still
notsatisfied, the physician can give more information.
60. When an unexpected death occurs in the ER, which of the following tasks is most
appropriate to delegate to the nursing assistant?
a. Escort the family to a place of privacy.
b. Go with the organ donor specialist to talk to the family.
c. Assist with postmortem care.
d. Assist the family to collect belongings.

ANSWER C – Postmortem care requires some turning, cleaning, lifting, etc., and the nursing
assistant is able to assist with these duties. The RN should take responsibility for the other
tasks to help the family begin the grieving process. In cases of questionable death,
belongings may be retained for evidence, so the chain of custody would have to be
maintained.
61. The most important action the nurse should do before and after suctioning a
client is:

a. Placing the client in a supine position

b. Making sure that suctioning takes only 10-15 seconds
c. Evaluating for clear breath sounds
d. Hyperventilating the client with 100% oxygen
62. The position of a conscious client during suctioning is:

a. Fowler's
b. Supine position
c. Side-lying
d. Prone
63. Presence of overdistended and non-functional alveoli is a condition called:

a. Bronchitis – inflammation of the mucus membranes of the bronchi

b. Emphysema
c. Empyema -  is a collection of pus in the space between the lung and the inner surface
of the chest wall (pleural space).
d. Atelectasis – lung collapse
64. The accumulation of fluids in the pleural space is called:

a. Pleural effusion
b. Hemothorax -  a collection of blood in the space between the chest wall and the lung
(the pleural cavity).
c. Hydrothorax - is a condition that results from serous fluid
accumulating in the pleural cavity
d. Pyothorax also known as pleural empyema
65. Nurse Madonna is caring for a client with a pneumothorax and who has had a
chest tube inserted notes continuous gentle bubbling in the suction control
 chamber. What action is appropriate?

a. Do nothing, because this is an expected finding.

b. Immediately clamp the chest tube and notify the physician.
c. Check for an air leak because the bubbling should be intermittent.
d. Increase the suction pressure so that bubbling becomes vigorous.
66. The nurse caring for a male client with a chest tube turns the client to the side,
and the chest tube accidentally disconnects. The initial nursing action is to:

a. Call the physician.

b. Place the tube in a bottle of sterile water.
c. Immediately replace the chest tube system.
d. Place the sterile dressing over the disconnection site.
67. While changing the tapes on a tracheostomy tube, the male client coughs and
the tube is dislodged. The initial nursing action is to:

a. Call the physician to reinsert the tube.

b. Grasp the retention sutures to spread the opening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.

If the chest drainage system is disconnected, the end of the tube is

placed in a bottle of sterile water held below the level of the chest.
The system is replaced if it breaks or cracks or if the collection
chamber is full. Placing a sterile dressing over the disconnection site
will not prevent complications resulting from the disconnection. The
physician may need to be notified, but this is not the initial action.
68. A nurse is caring for a male client immediately after removal of the
endotracheal tube. The nurse reports which of the following signs immediately
if experienced by the client?

a. Stridor
b. Occasional pink-tinged sputum
c. A few basilar lung crackles on the right
d. Respiratory rate of 24 breaths/min
69. An emergency room nurse is assessing a female client who has sustained a blunt
injury to the chest wall. Which of these signs would indicate the presence of a
pneumothorax in this client?

a. A low respiratory
b. Diminished breath sounds
c. The presence of a barrel chest
d. A sucking sound at the site of injury – open pneumothorax
70. A nurse is caring for a male client hospitalized with acute exacerbation of
chronic obstructive pulmonary disease. Which of the following would the nurse
expect to note on assessment of this client?

a. Hypocapnia
b. A hyperinflated chest noted on the chest x-ray
 c. Increase oxygen saturation with exercise
d. A widened diaphragm noted on the chest x-ray
71. A community health nurse is conducting an educational session with
community members regarding tuberculosis. The nurse tells the group that one
of the first symptoms associated with tuberculosis is:

a. Dyspnea
b. Chest pain
c. A bloody, productive cough
d. A cough with the expectoration of mucoid sputum
72. A nurse is caring for a male client with emphysema who is receiving oxygen. The
nurse assesses the oxygen flow rate to ensure that it does not exceed:

a. 1 L/min
b. 2 L/min
c. 6 L/min
d. 10 L/min
73. A nurse instructs a female client to use the pursed-lip method of breathing and
the client asks the nurse about the purpose of this type of breathing. The nurse
responds, knowing that the primary purpose of pursed-lip breathing is to:

a. Promote oxygen intake.

b. Strengthen the diaphragm.
c. Strengthen the intercostal muscles.
d. Promote carbon dioxide elimination.
74. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which
of the following nursing actions will facilitate obtaining the specimen?

a. Limiting fluids
b. Having the clients take three deep breaths
c. Asking the client to split into the collection container
d. Asking the client to obtain the specimen after eating
75. A nurse is caring for a female client after a bronchoscope and biopsy. Which of
the following signs, if noted in the client, should be reported immediately to the
physicians?

a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-streaked sputum
76. A nurse is suctioning fluids from a male client via a tracheostomy tube. When
suctioning, the nurse must limit the suctioning time to a maximum of:

a. 1 minute
b. 5 seconds
c. 10 seconds
d. 30 seconds
77. A nurse is suctioning fluids from a female client through an endotracheal tube.
During the suctioning procedure, the nurse notes on the monitor that the heart
 rate is decreasing. Which of the following is the appropriate nursing
intervention?

a. Continue to suction.
b. Notify the physician immediately.
c. Stop the procedure and reoxygenate the client.
d. Ensure that the suction is limited to 15 seconds.
78. A female client is suspected of having a pulmonary embolus. A nurse assesses
the client, knowing that which of the following is a common clinical
manifestation of pulmonary embolism?

a. Dyspnea
b. Bradypnea
c. Bradycardia
d. Decreased respiratory
79. A client with pneumonia is experiencing pleuritic chest pain. The nurse should
assess the client for: 
a. A mild but constant aching in the chest.
b. Severe midsternal pain. 
c. Moderate pain that worsens on inspiration. 
d. Muscle spasm pain that accompanies coughing.
80. Which of the following measures would most likely be successful in
reducing pleuritic chest pain in a client with pneumonia? 
a. Encourage the client to breathe shallowly. 
b. Have the client practice abdominal breathing. 
c. Offer the client incentive spirometry. 
d. Teach the client to splint the rib cage when coughing.
81. The nurse reviews an arterial blood gas report for a client with chronic
obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34
The nurse should: 
a. Apply a 100% non-rebreather mask. 
b. Assess the vital signs. 
c. Reposition the client. 
d. Prepare for intubation.
82. When developing a discharge plan to manage the care of a client with chronic
obstructive pulmonary disease (COPD), the nurse should advise the the client to
expect to: 
a. Develop respiratory infections easily. 
b. Maintain current status. 
c. Require less supplemental oxygen. 
d. Show permanent improvement.
83. Which of the following indicates that the client with chronic obstructive
pulmonary disease (COPD) who has been discharged to home understands his
care plan? 
a. The client promises to do pursed-lip breathing at home.
b. The client states actions to reduce pain. 
c. The client says that he will use oxygen via a nasal cannula at 5 L/ minute. 
d. The client agrees to call the physician if dyspnea on exertion
increases.
84. Which of the following physical assessment findings are normal for a client with
advanced chronic obstructive pulmonary disease (COPD)? 
a. Increased anteroposterior chest diameter. 
b. Underdeveloped neck muscles. 
c. Collapsed neck veins. 
d. Increased chest excursions with respiration.
85. When instructing clients on how to decrease the risk of chronic obstructive
pulmonary disease (COPD), the nurse should emphasize which of the
following? 
a. Participate regularly in aerobic exercises. 
b. Maintain a high-protein diet. 
c. Avoid exposure to people with known respiratory infections. 
d. Abstain from cigarette smoking.
86. Which of the following is an expected outcome of pursed-lip breathing for
clients with emphysema? 
a. To promote oxygen intake. 
b. To strengthen the diaphragm.
c. To strengthen the intercostal muscles. 
d. To promote carbon dioxide elimination.
87. Which of the following is a priority goal for the client with chronic obstructive
pulmonary disease (COPD)?
a. Maintaining functional ability. 
b. Minimizing chest pain. 
c. Increasing carbon dioxide levels in the blood. 
d. Treating infectious agents.
88. A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg;
PaCO2, 65 mm Hg; HCO3 −, 36 mEq/ L. The nurse should assess the client
for? 
a. Cyanosis. 
b. Flushed skin. 
c. Irritability. 
d. Anxiety.
89. When performing postural drainage, which of the following factors promotes
the movement of secretions from the lower to the upper respiratory tract? 
a. Friction between the cilia. 
b. Force of gravity. 
c. Sweeping motion of cilia. 
d. Involuntary muscle contractions.
90. When teaching a client with chronic obstructive pulmonary disease to conserve
energy, the nurse should teach the client to lift objects: 
a. While inhaling through an open mouth.
b. While exhaling through pursed lips. 
c. After exhaling but before inhaling. 
d. While taking a deep breath and holding it.
91. The nurse teaches a client with chronic obstructive pulmonary disease (COPD)
to assess for signs and symptoms of right-sided heart failure. Which of the
following signs and symptoms should be included in the teaching plan? 
a. Clubbing of nail beds. 
b. Hypertension. 
 c. Peripheral edema. 
d. Increased appetite.
92. The nurse assesses the respiratory status of a client who is experiencing an
exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an
upper respiratory tract infection. Which of the following findings would be
expected? 
a. Normal breath sounds.
b. Prolonged inspiration. 
c. Normal chest movement. 
d. Coarse crackles and rhonchi.
93. A client with chronic obstructive pulmonary disease (COPD) is experiencing
dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as
ordered. Which of the following statements is true concerning oxygen
administration to a client with COPD? 
a. High oxygen concentrations will cause coughing and dyspnea. 
b. High oxygen concentrations may inhibit the hypoxic stimulus to
breathe. 
c. Increased oxygen use will cause the client to become dependent on the
oxygen. 
d. Administration of oxygen is contraindicated in clients who are using
bronchodilators.
94. Which of the following diets would be most appropriate for a client with chronic
obstructive pulmonary disease (COPD)? 
a. Low-fat, low-cholesterol diet. 
b. Bland, soft diet. 
c. Low-sodium diet. 
d. High-calorie, high-protein diet.
95. The nurse administers theophylline (Theo-Dur) to a client. To evaluate the
effectiveness of this medication, which of the following drug actions should the
nurse anticipate? 
a. Suppression of the client's respiratory infection. 
b. Decrease in bronchial secretions. 
c. Relaxation of bronchial smooth muscle. 
d. Thinning of tenacious, purulent sputum.
96. The nurse is planning to teach a client with chronic obstructive pulmonary
disease how to cough effectively. Which of the following instructions should be
included? 
a. Take a deep abdominal breath, bend forward, and cough three or
four times on exhalation. 
b. Lie flat on the back, splint the thorax, take two deep breaths, and cough. 
c. Take several rapid, shallow breaths and then cough forcefully. 
d. Assume a side-lying position, extend the arm over the head, and alternate
deep breathing with coughing.
97. A 34-year-old female with a history of asthma is admitted to the emergency
department. The nurse notes that the client is dyspneic, with a respiratory rate
of 35 breaths/ minute, nasal flaring, and use of accessory muscles. Auscultation
of the lung fields reveals greatly diminished breath sounds. Based on these
findings, which action should the nurse take to initiate care of the client? 
a. Initiate oxygen therapy and reassess the client in 10 minutes. 
 b. Draw blood for an arterial blood gas analysis and send the client for a chest
X-ray. 
c. Encourage the client to relax and breathe slowly through the mouth. 
d. Administer bronchodilators.
98. A client with acute asthma is prescribed short-term corticosteroid therapy.
Which is the expected outcome for the use of steroids in clients with asthma? 
a. Promote bronchodilation. 
b. Act as an expectorant. 
c. Have an anti-inflammatory effect. 
d. Prevent development of respiratory infections.
99. A client who has been taking flunisolide (AeroBid), two inhalations a day, for
treatment of asthma.has painful, white patches in his mouth. Which response
by the nurse would be most appropriate? 
a. "This is an anticipated adverse effect of your medication. It should go away in
a couple of weeks." 
b. "You are using your inhaler too much and it has irritated your mouth." 
c. "You have developed a fungal infection from your medication. It
will need to be treated with an antifungal agent." 
d. "Be sure to brush your teeth and floss daily. Good oral hygiene will treat this
problem."
100. Which of the following is an appropriate expected outcome for an adult
client with well-controlled asthma? 
a. Chest X-ray demonstrates minimal hyperinflation. 
b. Temperature remains lower than 100 ° F (37. 8 ° C). 
c. Arterial blood gas analysis demonstrates a decrease in PaO2. 
d. Breath sounds are clear.