1. :Question -106106
A client in the telemetry unit is receiving an intravenous
infusion of 1000 mL of 5% dextrose in water (D 5W) plus
40 mEq of potassium chloride . Which of the following if
noted on the cardiac monitor would indicate the presence
?of hyperkalemia
:Options
Tall, peaked T waves . 1
ST-segment depression . 2
Shortening of the QRS complex . 3
Shortened PR interval . 4
:Answer
. 1
:Rationale
The signs and symptoms of hyperkalemia relate to the
effect of potassium on the myocardial muscle. These
include changes noted on the electrocardiogram (ECG),
such as tall and peaked T waves, prolonged PR interval,
widening of the QRS complex, shortening of the QT
interval, and disappearance of the P wave. Other cardiac
signs and symptoms include ventricular dysrhythmias that
may lead to cardiac arrest. ST-segment depression is noted
.in hypokalemia
:Question -107
A nurse in the telemetry unit is monitoring a client for
cardiac changes indicative of hypokalemia. Which of the
following if noted on the cardiac monitor would indicate

2. :the presence of hypokalemia? Options
Tall, peaked T wave . 1
ST-segment depression . 2
Widening of the QRS complex . 3
Prolonged PR interval . 4
:Answer
. 2
:Rationale
In the client with hypokalemia, the nurse would note ST-
segment depression on a cardiac monitor. The client also
may exhibit a flat T wave . Options 1 , 3 , and 4 are
cardiac monitor findings that would be noted in the client
.with hyperkalemia
:Question -108
A client is admitted to the visiting nurse services for
assessment and follow-up after being discharged from the
hospital for new-onset congestive heart failure (CHF). The
nurse teaches the client about the dietary restrictions
required with CHF. Which statement by the client
?indicates that further teaching is needed
:Options
I ’m going to have a ham and cheese sandwich and” . 1
“ .potato chips for lunch
I ’m going to weigh myself daily to be sure I don ’t” . 2
“ .gain too much fluid
“ .I can have most fresh fruits and fresh vegetables” . 3
“ .I ’m not supposed to eat cold cuts” . 4

3. :Answer
. 1
:Rationale
When a client has CHF, the goal is to reduce fluid
accumulation. One way that this is accomplished is sodium
reduction. Ham, cheese (and most cold cuts), 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
:Question -109
A nurse is performing health screening on a 54-year- old
client . The client has a blood pressure of 118/78 mm Hg ,
total cholesterol of 190 mg/dL , and fasting blood glucose
level of 184 mg/dL . The nurse interprets that the client
has which of the following modifiable risk factors for
?(coronary artery disease (CAD
:Options
Hypertension . 1
Glucose intolerance . 2
Age . 3
Hyperlipidemia . 4
:Answer
. 2
:Rationale
Hypertension, cigarette smoking, and hyperlipidemia are
modifiable risk factors that are predictors of CAD.

4. Glucose intolerance, obesity, and response to stress are
contributing modifiable risk factors to CAD . Age greater
than 40 is a nonmodifiable risk factor. The nurse places
.priority on risk factors that can be modified
:Question -110
A 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
:Options
I don ’t have anyone to help me with doing heavy” . 1
“ .housework at home
I think I have a good understanding of what all my” . 2
“ .medications are for
I will be sure to keep my appointment with the” . 3
“ .cardiologist
I need to start exercising more to improve my” . 4
“ .health
:Answer
. 1
:Rationale
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 following an MI. All of the options except
option 1 indicate that the client will be successful in these

5. . areas
:Question -111
A home care nurse has taught a client with a nursing
diagnosis of decreased cardiac output about helpful
lifestyle adaptations to promote health. Which of the
following statements by the client best demonstrates an
?understanding of the information provided
:Options
I will eat enough daily fiber to prevent straining at” . 1
“ .stool
Drinking 2 to 3 ounces of liquor each night will” . 2
promote blood flow by enlarging blood vessels . ”3 . “I will
drink 3000 to 3500 mL of fluid daily to promote good
“ . kidney function
I will try to exercise vigorously to strengthen my” . 4
“ .heart muscle
:Answer
. 1
:Rationale
Standard home care instructions for a client with this
nursing diagnosis 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

6. :Question .-112
A client has a nursing diagnosis of activity intolerance
related to 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 nursing diagnosis
:Options
Chooses a healthy diet that meets caloric needs . 1
Sleeps without awakening throughout the night . 2
Verbalizes the benefits of increasing activity . 3
Ambulates 10 feet farther each day . 4
:Answer
. 4
:Rationale
Each of the options indicates a positive outcome on the
part of the client . However, option 1 would most likely
indicate progress if the client had a nursing diagnosis of
imbalanced nutrition . Option 2 would be a satisfactory
outcome for disturbed sleep pattern . Both options 3 and 4
relate to the nursing diagnosis of activity intolerance .
However, the question asks about progress . Option 4 is
.more action - oriented and therefore is the better choice
:Question -113
The physician has written an order for a client to have an
echocardiogram. The nurse takes which of the following
?actions to prepare the client for the procedure
:Options

7. Questions the client about allergies to iodine or . 1
shellfish
Keeps the client on nothing by mouth (NPO) status . 2
for 2 hours before the procedure
Tells the client that the procedure is painless and . 3
takes 30 to 60 minutes
Has the client sign an informed consent form for an . 4
invasive procedure
:Answer
. 3
:Rationale
Echocardiography is a noninvasive, risk-free, pain-free
test that involves no special preparation. It commonly is
done at the bedside or on an outpatient basis . The client
must lie quietly for 30 to 60 minutes while the procedure is
being performed. It is important to provide adequate
information to eliminate unnecessary worry on the part of
.the client
:Question -114
The physician has written an order for a client to have an
echocardiogram. The nurse takes which of the following
?actions to prepare the client for the procedure
:Options
Questions the client about allergies to iodine or . 1
shellfish
Keeps the client on nothing by mouth (NPO) status . 2
for 2 hours before the procedure

8. Tells the client that the procedure is painless and . 3
takes 30 to 60 minutes
Has the client sign an informed consent form for an . 4
invasive procedure
:Answer
. 3
:Rationale
Echocardiography is a noninvasive, risk-free, pain-free
test that involves no special preparation. It commonly is
done at the bedside or on an outpatient basis . The client
must lie quietly for 30 to 60 minutes while the procedure is
being performed. It is important to provide adequate
information to eliminate unnecessary worry on the part of
.the client
:Question -115
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
?of the following sensations during the procedure
:Options
Pressure at the insertion site . 1
Urge to cough . 2
Warm, flushed feeling . 3
Chest pain . 4
:Answer
. 4
:Rationale

9. The client is taught to immediately report chest pain or
any unusual sensations. The client is informed that a
warm, flushed feeling may accompany dye injection and is
normal. The client also is told that he or she may be asked
to cough or breathe deeply from time to time during the
procedure. Because a local anesthetic is used, the client is
.expected to feel pressure at the insertion site
:Question -116
A client recovering from pulmonary edema is preparing
for discharge. The nurse plans to teach the client to do
which of the following to manage or prevent recurrent
?symptoms after discharge
:Options
Take a double dose of the diuretic if peripheral . 1
.edema is noted
Withhold prescribed digoxin (Lanoxin) if slight . 2
.respiratory distress occurs
.Weigh himself on a daily basis . 3
.Sleep with the head of bed flat . 4
:Answer
. 3
:Rationale
The client can best determine fluid status at home by
weighing himself on a daily basis . Increases of 2 to 3
pounds in a short time period are reported to the physician
. The client should sleep with the head of the bed elevated.
During recumbent sleep, fluid (which has seeped into the

10. interstitium by day with the assistance of the effects of
gravity) is rapidly reabsorbed into the systemic circulation.
Sleeping with the head of bed flat is therefore avoided. The
client does not modify medication dosages without
.consulting the physician
:Question -117
A client is scheduled to undergo cardiac catheterization for
the first time, and the nurse provides instructions to the
client. Which client statement indicates a clear
:understanding of the instructions? Options
I will have to go to the operating room for this” . 1
“ .procedure
I probably will feel tired after the test from lying on” . 2
“ .a hard x-ray table for a few hours
.It will really hurt when the catheter is first put in” . 3
“
.I will receive general anesthesia for the procedure” . 4
“
:Answer
. 2
:Rationale
It is common for the client to feel fatigued after the
cardiac catheterization procedure. Other pre- procedure
teaching points include that the procedure is done in a
darkened cardiac catheterization room. A local anesthetic
is used, so little to no pain is experienced with catheter
insertion. General anesthesia is not used . The x- ray table

11. 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
:Question -118
A client admitted to the hospital with coronary artery
disease complains of dyspnea at rest. A nurse caring for
the client uses which of the following items as the best
?means to monitor respiratory status on an ongoing basis
:Options
Oxygen flowmeter . 1
Oxygen saturation monitor . 2
Telemetry cardiac monitor . 3
Apnea monitor . 4
:Answer
. 2
:Rationale
Dyspnea in the cardiac client often is accompanied by
hypoxemia. Hypoxemia can be detected by an oxygen
saturation monitor, especially if used continuously. An
oxygen flowmeter is part of the setup for delivering oxygen
therapy. Cardiac monitors detect dysrhythmias. An apnea
monitor detects apnea episodes, such as when the client
.has stopped breathing briefly
:Question -119
A nurse has an order to remove the nasogastric (NG) tube
from a post–cardiac surgery client on the first
postoperative day. The nurse would question the order if

12. which of the following was noted on assessment of the
?client
:Options
.Bowel sounds are absent . 1
.The abdomen is slightly distended . 2
.NG tube drainage is Hematest negative . 3
.The client is drowsy . 4
:Answer
. 1
:Rationale
The NG tube should remain in place until the client has
bowel sounds. If bowel sounds do not return, the client
could have a paralytic ileus, which could result in
distention and vomiting if the NG tube is discontinued. It
is normal for NG tube drainage to be Hematest negative.
The abdomen is likely to be slightly distended after
surgery, and it also is likely that the client may be drowsy
.after experiencing a stressor such as cardiac surgery
:Question -120
A client recovering from cardiac surgery has a left pleural
effusion and is about to undergo a thoracentesis. The nurse
?places the client in which position for the procedure
:Options
Upright and leaning forward with the arms on an . 1
over-the-bed table
Right side-lying, with the legs curled up into a fetal . 2
position

13. Left lateral, with the right arm supported by a pillow . 3
Dorsal recumbent . 4
:Answer
. 1
:Rationale
The client undergoing thoracentesis usually sits in an
upright position, with the anterior thorax supported by
pillows, or leaning over an over-the-bed table. The client
must be placed in a position that will enlist the aid of
gravity in accessing and draining the effusion. Any form of
side-lying position will cause fluid to accumulate under
that side, which is inaccessible to the physician. The dorsal
.recumbent position also is an inaccessible position
:Question -121
A client receiving parenteral nutrition has a history of
congestive heart failure. The physician has ordered
furosemide (Lasix) 40 mg by mouth daily to prevent fluid
overload . The nurse monitors which laboratory value to
?identify an adverse effect from this medication
:Options
Glucose . 1
Sodium . 2
Potassium . 3
Magnesium . 4
:Answer
. 3

14. :Rationale
Furosemide is a non–potassium-sparing diuretic, and
insufficient replacement of potassium may lead to
hypokalemia. Although the glucose, sodium, and
magnesium levels may be monitored, these laboratory
.values are not specific to administering furosemide
:Question-122
A client with a history of recent upper respiratory
infection comes to the urgent care center complaining of
chest pain. The nurse interprets that the pain is most likely
of a respiratory origin if the client states which of the
?following about the pain
:Options
“ .It hurts on the left side of my chest” . 1
“ .I have never had this pain before” . 2
“ . The pain is about a 6 on a scale of 1 to 10” . 3
“ .It hurts more when I breathe in” . 4
:Answer
. 4
:Rationale
Chest pain is assessed using the standard pain assessment
parameters, such as, characteristics, location, intensity,
duration, precipitating and alleviating factors, and
associated symptoms. Pain of pleuropulmonary
.(respiratory) origin usually becomes worse on inspiration

15. :Question-123
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. The nurse interprets
that the client is experiencing which of the following types
?of angina
:Options
Stable . 1
Unstable . 2
Variant . 3
Intractable . 4
:Answer
. 1
:Rationale
Stable angina is triggered by a predictable amount of
effort or emotion. 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. 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. Intractable angina is chronic and
.incapacitating and is refractory to medical therapy
:Question -124
A client with a first-degree heart block has an
electrocardiogram (ECG) taken during an episode of chest

16. pain. The nurse interprets that which ECG finding
?indicates first-degree heart block
:Options
Prolonged PR interval . 1
Widened QRS complex . 2
Tall, peaked T waves . 3
Presence of Q waves . 4
:Answer
. 1
:Rationale
A prolonged PR interval indicates first-degree heart block.
A widened QRS complex indicates a delay in
intraventricular conduction, such as bundle branch block.
Tall, peaked T waves may indicate hyperkalemia. The
development of Q waves indicates myocardial necrosis. An
ECG taken during a pain episode is intended to capture
ischemic changes, which also includes ST-segment
.elevation or depression
:Question _125
A 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
:Options
I will take nitroglycerin whenever chest discomfort” . 1
“ .begins

17. I will use muscle relaxation to cope with stressful” . 2
“ .situations
“ .It is best to exercise once a week for 1 hour” . 3
“ .I will avoid using table salt with meals” . 4
:Answer
. 3
:Rationale
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 has caused the pain, and to take
.the medication at the first sign of chest discomfort
:Question _126
A home health nurse is visiting an older client whose
family has gone out for the day. During the visit, the client
experiences chest pain that is unrelieved by three
sublingual nitroglycerin tablets given by the nurse. Which
?action by the nurse would be appropriate at this time
:Options
.Notify a family member who is the next of kin . 1
Inform the home care agency supervisor that the visit . 2
.may be prolonged
Call for an ambulance to transport the client to the . 3
.hospital emergency department

18. .Drive the client to the physician ’s office . 4
:Answer
. 3
:Rationale
Chest pain that is unrelieved by rest and three doses of
nitroglycerin administered 5 minutes apart may not be
typical anginal pain but may signal myocardial infarction
(MI). Because the risk of sudden cardiac death is greatest
in the first 24 hours after MI , it is imperative that the
client receive emergency cardiac care. A physician ’s office
is not equipped to treat MI. Communication with the
family or home care agency delays client treatment, which
.is needed immediately
:Question _127
An ambulatory care nurse is working with a client who has
been diagnosed with Prinzmetal ’s (variant) angina. The
nurse plans to reinforce to the client that this type of
:angina
:Options
Is most effectively managed by β-blocking agents . 1
Generally is treated with calcium channel–blocking . 2
agents
Has the same risk factors as for stable and unstable . 3
angina
Can be controlled with a low-sodium, high-potassium . 4
diet

19. :Answer
. 2
:Rationale
Prinzmetal ’s angina results from spasm of the coronary
vessels and is treated with calcium channel blockers. The
risk factors are unknown, and this type of angina is
relatively unresponsive to nitrates. β- Blockers are
contraindicated because they may actually worsen the
.spasm. Diet therapy is not specifically indicated
:Question-128
A nurse working in a long-term care facility is assessing a
client experiencing chest pain. The nurse would interpret
that the pain is most likely due to myocardial infarction
(MI) on the basis of which of the following assessment
?findings
:Options
.The client is not experiencing nausea or vomiting . 1
The client says the pain began while she was trying to . 2
.open a stuck dresser drawer
The pain has not been relieved by rest and three . 3
.nitroglycerin tablets
.The client is not experiencing dyspnea . 4
:Answer
. 3
:Rationale
The pain of angina may radiate to the left shoulder, arm,

20. 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). The pain of MI is not relieved by
rest and nitroglycerin and requires opioid analgesics, such
.as morphine sulfate, for relief
:Question _129
A client is admitted to the hospital with a diagnosis of
myocardial infarction (MI) and is going to have an
intravenous nitroglycerin infusion started. Noting that the
client does not have an intra-arterial monitoring line in
place, the nurse obtains which of the following pieces of
:equipment for use at the bedside? Options
Central venous pressure (CVP) insertion tray . 1
Noninvasive blood pressure monitor . 2
Defibrillator . 3
Pulse oximeter . 4
:Answer
. 2
:Rationale
Nitroglycerin dilates both arteries and veins, causing
peripheral blood pooling, thereby reducing preload,

21. afterload, and myocardial work. This also accounts for the
primary side effect of nitroglycerin, which is hypotension.
In the absence of continuous direct arterial pressure
(intra-arterial) monitoring, the nurse should use an
automatic noninvasive blood pressure monitor. Options 1 ,
3 , and 4 are not specifically associated with the
.administration of intravenous nitroglycerin
:Question _130
A client with myocardial infarction (MI) has been
transferred from the coronary care unit (CCU) to the
general medical unit. The nurse encourages which of the
following activity levels for the client immediately after
?transfer
:Options
Ad lib activities because the client will be discharged . 1
soon
Unsupervised hallway ambulation for distances up to . 2
200 feet
Bathroom privileges and self-care activities . 3
Strict bed rest for 24 hours after transfer . 4
:Answer
. 3
:Rationale
On transfer from CCU to an intermediate care or general
medical unit, the client is allowed self-care activities and
bathroom privileges. It is unnecessary and possibly

22. 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
:Question _131.
A client with no history of heart disease has experienced
acute myocardial infarction and has been given
thrombolytic therapy with t-PA (tissue plasminogen
activator). The nurse identifies which of the following
assessment findings as the most likely indicator that the
?client is experiencing complications of this therapy
:Options
Tarry stools . 1
Nausea and vomiting . 2
Decreased urine output . 3
Orange-colored urine . 4
:Answer
. 1
:Rationale
Thrombolytic agents are used to dissolve existing thrombi,
and the nurse must 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 “hematesting ”secretions
for occult blood . Option 1 is the only option that indicates
. the presence of blood

23. :Question _132
A nurse is discussing smoking cessation with a client
diagnosed with coronary artery disease (CAD). Which
statement would the nurse make to try to motivate the
?client to quit smoking
:Options
If you quit now , your risk of cardiovascular disease” . 1
“ .will decrease to that of a nonsmoker in 3 to 4 years
Because most of the damage has already been done,” . 2
it will be all right to cut down a little at a time. ”3 . “If
you totally quit smoking right now, you can cut your
cardiovascular risk to zero within a year. ”4 . “None of the
cardiovascular effects are reversible, but quitting might
:prevent lung cancer. ” Answer
. 1
:Rationale
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 . Options 2 , 3 , and 4
. are incorrect
:Question _133
A client with heart failure is scheduled to be discharged to
home with digoxin (Lanoxin) and furosemide (Lasix) as
daily prescribed medications. The nurse tells the client to
report which of the following as an indication that the
?medications are not having the intended effect

24. :Options
Cough accompanied by other signs of respiratory . 1
infection
Sudden increase in appetite . 2
Weight gain of 2 to 3 pounds in a few days . 3
Increased urine output during the day . 4
:Answer
. 3
:Rationale
Clients with heart failure should immediately report
weight gain, loss of appetite, shortness of breath with
activity, edema, persistent cough, and nocturia. An
increase in urine output during the day is expected with
diuretic therapy (Lasix). A cough due to respiratory
infection does not necessarily indicate that heart failure is
.worsening
:Question _134
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 of the following
:breath sounds are noted? Options
Crackles throughout the lung fields . 1
Crackles in the bases . 2
Wheezes . 3
Rhonchi . 4
:Answer
. 2

25. :Rationale
Pulmonary edema is characterized by extreme
breathlessness, dyspnea, air hunger, and the production of
frothy, pink-tinged sputum. Auscultation of the lungs
reveals crackles throughout the lung fields. 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 would indicate full resolution of the
episode.) Wheezes and rhonchi are not associated with
.pulmonary edema
:Question _135 .
A client with pulmonary edema has an order to receive
morphine sulfate intravenously. The nurse determines that
the client is experiencing an intended effect of the
medication as indicated by which of the following
?assessment findings
:Options
Relief of apprehension . 1
Decreased urine output . 2
Increased pulse rate . 3
Increased blood pressure . 4
:Answer
. 1
:Rationale
Morphine sulfate reduces anxiety and dyspnea in the client
with pulmonary edema. It also promotes peripheral
vasodilation and causes blood to pool in the periphery. It

26. decreases pulmonary capillary pressure, which reduces
fluid migration into the alveoli. The client receiving
morphine sulfate is monitored for signs and symptoms of
respiratory depression and extreme drops in blood
pressure, especially when it is administered intravenously .
Options 2 , 3 , and 4 are unrelated to the action of
.morphine sulfate
:Question _136
The client who has experienced a myocardial infarction
(MI) is recovering from cardiogenic shock. The nurse
interprets that which observation of the client ’s clinical
?condition is most favorable
:Options
Central venous pressure (CVP) of 15 mm Hg . 1
(Frequent premature ventricular contractions (PVCs . 2
Urine output of 40 mL/hr . 3
Heart rate of 110 beats/min . 4
:Answer
. 3
:Rationale
Urine output of greater than 30 mL/hr indicates adequate
perfusion to the kidneys , so the other organs are most
likely equally perfused. Classic cardiovascular signs of
cardiogenic shock include low blood pressure and
tachycardia. The CVP rises as the effects of the backward
blood flow of the left ventricular failure became apparent.

27. Arrhythmias commonly occur as a result of decreased
oxygenation to the myocardium and are not a favorable
.sign
:Question _137
A client is scheduled to begin therapy with acetazolamide
(Diamox) for the management of glaucoma. Before
initiating therapy, the nurse asks the client about a history
:of allergy or sensitivity to: Options
Corticosteroids . 1
Nonsteroidal anti-inflammatory agents . 2
Penicillin . 3
Sulfa drugs . 4
:Answer
. 4
:Rationale
Acetazolamide is a carbonic anhydrase inhibitor that
contains sulfonamide properties. Before administration of
this medication, the client should be assessed for an allergy
to sulfonamides because the medication is contraindicated
if an allergy exists. The client also should be monitored
during therapy for an allergic reaction and for
.photosensitivity
:Question _138.
A client recovering from an exacerbation of left-sided
heart failure has a nursing diagnosis of activity
intolerance. Which of the following changes in vital signs
during activity would be the best indicator that the client is

28. ?tolerating mild exercise
:Options
Pulse rate increased from 80 beats/min to 104 beats/ . 1
. min
Respiratory rate increased from 16 breaths/min to 19 . 2
. breaths/min
. Oxygen saturation decreased from 96% to 91% . 3
Blood pressure decreased from 140/86 mm Hg to . 4
. 112/72 mm Hg
. Answer: 2
:Rationale
Vital signs that remain near baseline indicate good cardiac
reserve with exercise . Options 1 and 3 are incorrect
because they represent changes from normal values to
abnormal ones. Blood pressure decrease by more than 10
mm Hg is not a sign that indicates tolerance of activity .
Only the respiratory rate remains within the normal
.range. Additionally, it reflects a minimal increase