Cardiac
A client with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with worsening dyspnea, orthopnea, and a 5-lb weight gain in 3 days. The nurse auscultates an S3 gallop. Which lab result would the nurse anticipate?
a. Hemoglobin 18 g/dL
b. BNP 980 pg/mL
c. Potassium 3.0 mEq/L
d. Troponin I 0.01 ng/mL
b. BNP 980 pg/mLA high BNP indicates volume overload and worsening heart failure. S3 gallop is a classic sign.
A client with aplastic anemia is admitted for severe pancytopenia. Which of the following interventions should the nurse prioritize?
a. Encourage high-protein, high-calorie meals
b. Limit visitors and implement protective isolation
c. Apply warm compresses to injection sites
d. Administer iron supplements orally as prescribed
b. Limit visitors and implement protective isolation
Pancytopenia includes leukopenia, increasing infection risk. Protective isolation is priority.
A client’s telemetry strip shows a new onset of atrial fibrillation with a ventricular rate of 140 bpm. The client reports palpitations and dizziness. What is the nurse’s priority intervention?
a. Administer oxygen via nasal cannula
b. Prepare for immediate cardioversion
c. Notify the provider and assess vital signs
d. Document the rhythm and continue monitoring
c. Notify the provider and assess vital signs
Afib with rapid ventricular rate can lead to instability; assessing stability is priority.
A nurse is assessing a client with status asthmaticus who is receiving high-flow oxygen. The client suddenly becomes quiet with minimal wheezing and shows decreased respiratory effort. What is the nurse’s priority action?
a. Notify the rapid response team
b. Administer a rescue bronchodilator
c. Place the client in high Fowler’s position
d. Continue monitoring and reassess in 10 minutes
a. Notify the rapid response team
A sudden drop in wheezing and effort indicates impending respiratory failure—emergency support is needed.
A nurse is caring for a client diagnosed with acute pyelonephritis. Which symptom should the nurse expect the client to report?
a. Painless hematuria
b. Flank pain and fever
c. Polyuria without pain
d. Difficulty starting the urine stream
b. Flank pain and feverClassic symptoms of acute pyelonephritis include fever, chills, and flank pain due to kidney inflammation.
A nurse is caring for a client with unstable angina who is scheduled for cardiac catheterization. The client reports chest pain 7/10 and shortness of breath. What is the priority nursing action?
a. Administer prescribed morphine sulfate
b. Notify the provider of worsening symptoms
c. Reassess the pain in 15 minutes
d. Position the client in a high Fowler’s position
a. Administer prescribed morphine sulfate
Pain and ischemia must be treated immediately to prevent infarction; morphine reduces preload and pain.
A client with heparin-induced thrombocytopenia (HIT) is receiving IV heparin for a pulmonary embolism. The platelet count dropped from 210,000 to 85,000 in 24 hours. What is the nurse’s priority action?
a. Stop the heparin infusion and notify the provider
b. Continue therapy and monitor platelets daily
c. Administer fresh frozen plasma
d. Prepare for platelet transfusion
a. Stop the heparin infusion and notify the provider
A rapid platelet drop is a sign of HIT, which requires stopping all heparin immediately.
A nurse observes the following rhythm on the cardiac monitor: irregular rhythm, absent P waves, narrow QRS complexes, and fibrillatory baseline. What rhythm is this?
a. Ventricular fibrillation
b. Supraventricular tachycardia (SVT)
c. Atrial fibrillation
d. Sinus tachycardia
c. Atrial fibrillation
Irregular rhythm, absent P waves, and fibrillatory baseline are classic signs of Afib.
A client with pulmonary embolism (PE) is receiving IV heparin. Which of the following requires immediate notification to the provider?
a. aPTT of 65 seconds
b. Sudden onset of hemoptysis and chest pain
c. Heart rate of 100 bpm
d. Slight warmth and erythema at the IV site
b. Sudden onset of hemoptysis and chest pain
These signs may indicate PE progression or bleeding and require urgent provider notification.
A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L. What is the nurse's priority intervention?
a. Administer oral potassium chloride
b. Encourage potassium-rich foods
c. Prepare the client for dialysis
d. Place the client on a cardiac monitor
d. Place the client on a cardiac monitor Hyperkalemia (>6.0) can cause life-threatening arrhythmias. Cardiac monitoring is the priority.
A client with a mechanical mitral valve replacement is on warfarin therapy. The nurse reviews the client’s INR level of 5.8. What is the best nursing action?
a. Hold warfarin and administer vitamin K as prescribed
b. Continue the current warfarin dose and monitor for bleeding
c. Notify the provider only if signs of bleeding appear
d. Document the finding and schedule the next INR in 3 days
a. Hold warfarin and administer vitamin K as prescribed
An INR >5 places the client at high risk of bleeding and needs reversal per protocol.
A nurse is reviewing the laboratory values of a client with disseminated intravascular coagulation (DIC). Which of the following would the nurse expect to find?
a. Elevated platelet count and prolonged PT
b. Decreased fibrinogen and elevated D-dimer
c. Increased hemoglobin and hematocrit
d. Decreased PT and PTT with normal fibrinogen
b. Decreased fibrinogen and elevated D-dimer
In DIC, clotting factors are consumed; elevated D-dimer reflects fibrin degradation.
A client is found unresponsive with pulseless electrical activity (PEA) on the cardiac monitor. What is the first nursing action?
a. Begin CPR and follow ACLS protocol
b. Defibrillate the client immediately
c. Administer epinephrine IV push
d. Perform synchronized cardioversion
a. Begin CPR and follow ACLS protocol
PEA requires immediate high-quality CPR, not defibrillation.
A client is post-op day 1 from an abdominal surgery. The nurse notices the client has shallow respirations, low-grade fever, and diminished breath sounds at the bases. What is the nurse’s priority action?
a. Notify the healthcare provider for a stat chest X-ray
b. Encourage incentive spirometry and ambulation
c. Administer prescribed antipyretics
d. Increase the client’s IV fluid rate
b. Encourage incentive spirometry and ambulation
The client is showing early signs of atelectasis, common post-op; prevention is key.
The nurse is teaching a client with recurrent urinary tract infections (UTIs). Which statement indicates the need for further teaching?
a. “I will urinate after sexual intercourse.”
b. “I will wipe from front to back.”
c. “I will avoid drinking too much water.”
d. “I will avoid using douches and scented hygiene sprays.”
c. “I will avoid drinking too much water.”This indicates poor understanding. Adequate hydration helps flush bacteria.
A client in the ICU with a recent myocardial infarction has a new onset of a loud systolic murmur and hypotension. The nurse suspects papillary muscle rupture. What action should the nurse take first?
a. Prepare for echocardiography
b. Notify the provider immediately
c. Administer IV fluids
d. Increase oxygen to 100% via non-rebreather
b. Notify the provider immediately
Papillary muscle rupture is life-threatening and leads to acute mitral regurgitation – urgent surgical evaluation is needed.
A client with sickle cell disease presents with acute chest syndrome. Which assessment finding requires immediate intervention?
a. Chest pain and productive cough
b. Oxygen saturation of 88% on room air
c. Temperature of 100.8°F (38.2°C)
d. Fatigue and joint pain
b. Oxygen saturation of 88% on room air
Acute chest syndrome can rapidly lead to respiratory failure. Hypoxia requires urgent treatment.
A client’s rhythm strip shows 3 or more consecutive premature ventricular contractions (PVCs) with a wide QRS, rate of 160 bpm, and no P waves. What rhythm is this?
a. Ventricular fibrillation
b. Ventricular tachycardia
c. Atrial flutter
d. Accelerated idioventricular rhythm
b. Ventricular tachycardia
A run of 3+ PVCs with wide QRS and high rate is diagnostic for VTach.
A client with tuberculosis is started on isoniazid (INH), rifampin, ethambutol, and pyrazinamide. The client reports blurred vision and color changes. What is the nurse’s best response?
a. "This is a normal side effect and will resolve after treatment."
b. "You may be experiencing ethambutol toxicity; I’ll notify your provider."
c. "Drink more fluids to flush the medication through your kidneys."
d. "Discontinue all your medications until the symptoms resolve."
b. "You may be experiencing ethambutol toxicity; I’ll notify your provider."
Ethambutol can cause optic neuritis, which is dose-dependent and needs immediate attention.
A nurse is caring for a client with glomerulonephritis. Which of the following assessments indicates the client is developing a life-threatening complication?
a. Hematuria and proteinuria
b. Periorbital edema and fatigue
c. Crackles in the lungs and elevated blood pressure
d. Decreased urine output and dark-colored urine
c. Crackles in the lungs and elevated blood pressureThis suggests fluid overload leading to pulmonary edema, which is life-threatening.
Cardiac Case Study: Mr. Taylor – Heart Failure Exacerbation
Client Information:
Name: Mr. Leonard Taylor
Age: 68
Medical History: Hypertension, Type 2 Diabetes, Heart Failure with reduced ejection fraction (HFrEF, EF 30%)
Medications: Furosemide, Lisinopril, Metoprolol, Metformin
Allergies: None
🏥 Situation:
Mr. Taylor presents to the emergency department with increasing shortness of breath, fatigue, and a 7-lb weight gain over the past 5 days. He reports waking up at night gasping for air (paroxysmal nocturnal dyspnea) and having to sleep with three pillows. He denies chest pain but says, “My legs are swollen again.”
🩺 Assessment Findings:
Vital Signs:
BP: 158/92 mm Hg
HR: 104 bpm, regular
RR: 24/min
Temp: 98.4°F
O₂ Sat: 90% on room air
Physical Exam:
Bilateral pitting edema in lower extremities
Crackles in both lung bases
Jugular vein distention (JVD) present
Fatigued appearance, mild respiratory distress
Diagnostics:
BNP: 950 pg/mL (↑)
Serum potassium: 3.2 mEq/L (↓)
Creatinine: 1.4 mg/dL
EKG: Normal sinus rhythm
Chest X-ray: Pulmonary congestion
Ejection Fraction: 30% confirmed on echocardiogram
Which clinical findings confirm that Mr. Taylor is experiencing a heart failure exacerbation?
Select all that apply:
a. Elevated BNP
b. Bradycardia
c. Crackles in lung bases
d. Weight gain
e. Potassium level of 3.2 mEq/L
a, c, d
These are hallmark signs of worsening HFrEF. Low K+ is common but not diagnostic for HF itself.
The nurse is providing discharge teaching to a client newly diagnosed with iron deficiency anemia. Which of the following instructions should the nurse include in the teaching?
Select all that apply:
a. Eat more foods like red meat, leafy greens, and fortified cereals
b. Take iron supplements with milk to reduce stomach upset
c. Expect dark or black stools while taking iron
d. Use a straw when taking liquid iron supplements
e. Take iron with vitamin C-rich juice to improve absorption
f. Iron should always be taken on an empty stomach, even if it causes nausea
a, c, d, e
a✅ Yes Iron-rich foods help correct iron deficiency.
c✅ Yes Black stools are a normal and harmless side effect of oral iron.
d✅ Yes Using a straw prevents teeth staining from liquid iron.
e✅ Yes Vitamin C enhances absorption of iron supplements (e.g., orange juice).
A nurse is reviewing telemetry and notes that a client is in monomorphic ventricular tachycardia (VT) with a heart rate of 160 bpm. The client is awake but dizzy and hypotensive.
Which of the following actions should the nurse anticipate or take?
Select all that apply:
a. Prepare for immediate synchronized cardioversion
b. Defibrillate the client at 200 joules
c. Administer amiodarone IV as prescribed
d. Continue to monitor the rhythm without intervention
e. Obtain a 12-lead ECG before initiating treatment
f. Establish IV access and ensure emergency equipment is at bedside
g. Initiate chest compressions immediately
a, c, f
✅ A. Yes Synchronized cardioversion is indicated for unstable VTach with a pulse (hypotension, dizziness).
c✅ Yes IV amiodarone is often used to stabilize the rhythm in VTach, especially if cardioversion is delayed.
f✅ Yes IV access and emergency equipment (code cart, airway tools) are essential prep for cardioversion.
A nurse is caring for a client in acute respiratory failure due to exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following clinical manifestations should the nurse expect?
Select all that apply:
a. Restlessness and confusion
b. Respiratory rate of 10 breaths/min
c. PaCO₂ of 68 mm Hg
d. Use of accessory muscles during breathing
e. pH of 7.52
f. Cyanosis and cool, clammy skin
g. Hyperresonance to percussion
a, c, d, f
A nurse is caring for a child recently diagnosed with acute glomerulonephritis following a streptococcal infection. Which of the following clinical findings or nursing actions are expected or appropriate?
Select all that apply:
a. Hematuria that appears tea-colored or smoky
b. Periorbital and peripheral edema
c. Administration of corticosteroids to reduce proteinuria
d. Elevated serum creatinine and blood urea nitrogen (BUN)
e. Severe hypotension and risk for shock
f. Positive ant streptolysin O (ASO) titer
g. Strict monitoring of intake and output
a, b, d, f, g
a✅ YesTea-colored hematuria is classic for glomerulonephritis due to RBC breakdown and renal inflammation.
b✅ YesEdema, especially periorbital in the morning, is common due to fluid retention and sodium imbalance.
d✅ YesBUN and creatinine rise due to impaired glomerular filtration.
f✅ YesA positive ASO titer confirms a recent streptococcal infection, the trigger for AGN.
g✅ YesI&O monitoring is essential to assess renal function and fluid status.