2. Decreased creatine kinase
3. Increased troponin
4. High normal potassium
Question 17
Type: MCSA
A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal
output. What NANDA nursing diagnosis problem statement should the nurse choose for this client?
1. Ineffective Tissue Perfusion
2. Decreased Cardiac Output
3. Activity Intolerance
4. Risk for Injury
Question 18
Type: MCSA
A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health?
1. Place pillows under the unaffected knee for support.
2. Position the bed to flex the knees at least 20 degrees.
3. Have the client alternately flex and extend the feet several times a day.
4. Keep the client in a prone position for at least 20 minutes twice a day.
Question 19
Type: MCSA
The nurse finds a client pulseless and breathless. The client’s skin is pale and cool, but not cyanotic. Because of
this finding, what should the nurse suspect?
1. Respiratory arrest occurred prior to cardiac arrest.
2. Cardiac arrest occurred prior to respiratory arrest.
3. The client cannot be resuscitated.
4. Arrest was caused by airway obstruction.
Question 20
Type: MCSA
A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving
medications for which purpose?
1. To increase preload
2. To decrease afterload
3. To decrease contractility
4. To decrease cardiac output
Question 21
Type: SEQ
The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply
these devices?
Standard Text: Click and drag the options below to move them up or down.
1. Place in the dorsal recumbent or semi-Fowler’s position.
2. Place a sleeve under each leg with the opening at the knee.
3. Wrap the sleeve securely around the leg, securing the Velcro tabs.
4. Turn on the control unit and adjust the alarms and pressures as needed.
5. Connect the sleeves to the control unit and adjust the pressure as needed.
Question 22
Type: MCSA
The nurse is planning morning care for a client who has sequential compression devices in place. How should the
nurse instruct the UAP who will be giving the bath?
1. “Come get me when it is time to remove the devices, because that must be done by a nurse.”
2. “You may remove the devices, but standards require that only a nurse put them back on the client.”
3. “You may leave the devices off until the client’s legs air dry.”
4. “Put the devices on as quickly as possible after the bath.”
Question 23
Type: MCSA
The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this child’s blood pressure?
1. Yes, blood pressure is measured for all children over the age of 3 years.
2. No, blood pressure measurements are not required until age 13.
3. Only if the child complains of headache or has an elevated pulse rate.
4. Yes, but the measurement must be taken in the child’s thigh.
Question 24
Type: MCMA
A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration
in cardiovascular functioning?
Standard Text: Select all that apply.
1. Chronic fatigue
2. Lower-extremity edema
3. Pallor
4. Shortness of breath
5. Hypotension
Question 25
Type: MCSA
The nurse seeing a client stop breathing realizes that there is how much time before the onset of permanent
damage?
1. 3 minutes
2. 2 minutes
3. 4 to 6 minutes
4. 20 to 40 minutes
Question 26
Type: MCSA
A client with a terminal illness without an advance directive stops breathing, and does not have a heartbeat. What
should the nurse do?
1. Call a “slow code.”
2. Call a partial code.
3. Call the physician.
4. Call a code.
Question 27
Type: MCSA
A client asks why sequential compression devices have been prescribed. How should the nurse respond to the
client?
1. “They stimulate the blood return that would occur with walking.”
2. “They prevent lymph drainage buildup in the tissues.”
3. “They exercise the muscles of the leg.”
4. “They are used instead of walking out of bed.”
Question 28
Type: MCSA
The nurse determines that UAP can apply sequential compression devices to a client when what is observed?
1. The devices are left off for 1 hour after morning care.
2. The alarm is turned off.
3. The tubing is not kinked.
4. Ankle pressure is set at 100 mm Hg.
Question 29
Type: MCMA
The nurse is documenting the use of sequential compression devices in a client’s medical record. What should be
included in this documentation?
Standard Text: Select all that apply.
1. Calf circumference
2. Skin integrity
3. Peripheral vascular status
4. Neurovascular status
5. Control unit settings
Question 30
Type: MCSA
After an assessment, the nurse determines that a client’s sequential compression devices need to be removed.
What should the nurse document about this client’s status in the medical record?
1. Client ambulating without assistance.
2. Client complains of numbness, tingling, and leg pain with the sequential compression devices.
3. Client requested devices to be removed.
4. Client to wear sequential compression devices during sleep.