1. A patient is admitted with acute chest pain and shortness of breath. The nurse anticipates that the physician will order which diagnostic test to confirm a myocardial infarction?
• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gas (ABG)
• D. Magnetic resonance imagi...
1. A patient is admitted with acute chest pain and shortness of breath. The nurse
anticipates that the physician will order which diagnostic test to confirm a
myocardial infarction?
• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gas (ABG)
• D. Magnetic resonance imaging (MRI)
Correct Answer: A. Electrocardiogram (ECG)
• Rationale: An ECG is the first diagnostic test used to confirm a myocardial infarction. It
can identify ST-segment elevations or depressions, T-wave changes, and pathological Q
waves indicative of ischemia or infarction. Chest X-ray and MRI are not immediate
diagnostic tools for MI, and ABG measures oxygenation, not cardiac ischemia.
2. Which laboratory value is the most specific for detecting myocardial damage?
• A. Creatinine kinase (CK)
• B. Lactate dehydrogenase (LDH)
• C. Troponin
• D. Myoglobin
Correct Answer: C. Troponin
• Rationale: Troponin is the most specific and sensitive biomarker for myocardial damage.
Elevated troponin levels confirm myocardial injury. CK, LDH, and myoglobin are less
specific to cardiac tissue and may be elevated in other conditions.
3. A patient with a history of heart failure is prescribed furosemide (Lasix). The
nurse should monitor for which potential side effect?
• A. Hyperkalemia
• B. Hypokalemia
• C. Hypertension
• D. Tachycardia
Correct Answer: B. Hypokalemia
• Rationale: Furosemide is a loop diuretic that promotes the excretion of potassium, which
can lead to hypokalemia. Hyperkalemia is less likely unless there is concurrent
, potassium-sparing diuretic therapy. Furosemide can cause hypotension due to volume
depletion.
4. A patient is recovering from coronary artery bypass graft (CABG) surgery.
Which intervention is a priority for preventing postoperative complications?
• A. Ambulate the patient as soon as possible
• B. Maintain the patient on strict bed rest
• C. Administer IV fluids to maintain hydration
• D. Limit deep breathing exercises
Correct Answer: A. Ambulate the patient as soon as possible
• Rationale: Early ambulation is essential for preventing complications such as deep vein
thrombosis (DVT) and pneumonia. Bed rest can increase the risk of these complications.
Deep breathing exercises should be encouraged to promote lung expansion.
5. A nurse is assessing a patient for signs of digoxin toxicity. Which of the
following is an early indication of toxicity?
• A. Bradycardia
• B. Visual disturbances
• C. Confusion
• D. Nausea and vomiting
Correct Answer: D. Nausea and vomiting
• Rationale: Early signs of digoxin toxicity include gastrointestinal symptoms like nausea
and vomiting. Other signs, such as bradycardia, visual disturbances, and confusion, may
occur later.
6. A patient with atrial fibrillation is prescribed warfarin (Coumadin). What is
the most important laboratory test to monitor during therapy?
• A. Hemoglobin
• B. Platelet count
• C. International normalized ratio (INR)
• D. Activated partial thromboplastin time (aPTT)
Correct Answer: C. International normalized ratio (INR)
, • Rationale: The INR is used to monitor the effectiveness of warfarin therapy and ensure
the patient is within the therapeutic range (typically 2.0–3.0 for atrial fibrillation). aPTT
is used for heparin therapy.
7. A patient with chronic heart failure reports a 5-pound weight gain over two
days. What action should the nurse take?
• A. Educate the patient on reducing caloric intake
• B. Reassure the patient that this is normal for heart failure
• C. Notify the healthcare provider
• D. Instruct the patient to stop taking diuretics
Correct Answer: C. Notify the healthcare provider
• Rationale: A rapid weight gain in heart failure patients is often due to fluid retention and
indicates worsening heart failure. The healthcare provider should be notified for potential
adjustments in diuretic therapy or other interventions.
8. The nurse is caring for a patient who just underwent a percutaneous coronary
intervention (PCI) with stent placement. What is the priority nursing
assessment?
• A. Monitoring for signs of infection
• B. Assessing the site for bleeding
• C. Monitoring blood pressure hourly
• D. Measuring urine output
Correct Answer: B. Assessing the site for bleeding
• Rationale: Bleeding at the insertion site is the most critical complication after PCI, as the
femoral artery is often accessed. Monitoring for infection is important but is not the
immediate concern post-procedure.
9. A patient is receiving nitroglycerin IV for chest pain. Which vital sign is the
most important for the nurse to monitor?
• A. Respiratory rate
• B. Blood pressure
• C. Oxygen saturation
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