Sample Exam with Category Analysis and Exam Plan - Western Wyoming

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Sample Exam with Category Analysis and Exam Plan - Western Wyoming Powered By Docstoc
					December 11, 2008

The first section of this document is an example of the tool employed by the Western
Wyoming Community College (WWCC) Nursing Department for the purpose of
correlating exam questions with the stated content objectives associated with a
particular Problem-Based Learning (PBL) case study.

The second section presents a sample of an actual theory exam that accompanies the
corresponding PBL case. Appearing after the exam questions are tables employed to
ensure correlation of the WWCC nursing exam with NCLEX exam plan categories and
to ensure equivalent distribution of content areas across multiple versions of the exam.

Copyright WWCC Nursing Department                            Exam Plan/Exam example document
                                          BN3 Emma Goldblum Case B Exam Plan
Objectives                                                                  Version 1                      Version 2     Final
Communicate Competently                                                                      19            20          13
Communicator                                                                                 21
 Therapeutic Communication
Utilize effective communication techniques to enhance the therapeutic relationship for
patients experiencing anxiety and denial.
Incorporate feedback from health care experts.

Utilize appropriate channels of communication to share relevant, prioritized data verbally
and in writing with health team members.

Document to meet the standards of the profession using standards of care and clinical
Evaluate the discharge teaching needs of the patient in this case.                                                     28
Formulate teaching plans for the patient experiencing complex health problems in this        18                        13
case.                                                                                                                  57

Differentiate facility based/home based cardiac rehab programs.

Identify techniques that convey caring and non-caring behaviors to patient with
ineffective coping.
See Issues from Multiple Perspectives                                                                                  78
Examine ways to adapt nursing care to meet the needs of special populations (elderly,
chronically ill) in the rural culture.
Analyze the influence of the family unit on discharge planning.

Discuss the way family members influence one another's health.

Assess families as care givers.

Identify strategies to advocate for clients’ rights in this case.
Identify contemporary ethical issues and nursing implications.

Psycho-Social Dimensions                                                                                   21          83
Explain how complex health problems affect:                                                                9
       a. growth and development
       b. social interaction
       c. coping
       e. end of life issues
Identify various coping strategies that can be employed to deal with chronic illness.        23                        88

Explore the role of denial in patients with MI.                                              20            19

Copyright WWCC Nursing Department                                                                 Exam Plan/Exam example document
                                          BN3 Emma Goldblum Case B Exam Plan
Objectives                                                                  Version 1                         Version 2     Final
Discuss common fears/anxieties of post MI patients or patients with new onset of chronic        22            22
illness.                                                                                                      23

Develop Life Skills
Discipline of Nursing
Discuss practicing within the scope of nursing according to the Nurse Practice Act.
Life Long Learning
Demonstrate life long learning (curiosity, preparedness, thorough investigation, changing
decisions based on changing knowledge).
Manager                                                                                         1             1           4
Organization                                                                                    9                         10
Explain how staff can be organized to meet patient care needs                                                             11
Cost Effective Care
Discuss cost effective referral resources for patients discharged to home after serious
Solve Problems
Critical Thinking in Decision Making
Make theoretical nursing judgments based on knowledge, experience, and standards of
Identify the priority questions required to elicit pertinent and relevant patient information
in order to make sound nursing decisions
Challenge Assumptions
Challenge assumptions related to the nursing care of the patient experiencing denial and
Prioritize                                                                                                                6
Consistently address priority needs in the nursing care of the patient throughout this case.                              7
Complete the following statement, "All patients with chronic illness are………………..”

Retrieve Information
Examine current nursing research and its application to clinical practice.
Begin to apply Evidence Based Practice.

Informatics                                                                                     11
Identify community /internet resources to assist patients in meeting their health care
Use the language of the profession of nursing.

Apply Therapeutic Nursing Interventions
Nursing Process
Apply the steps of the nursing process to this case:

Discuss ways to modify physical assessment techniques.                                          24                        25

Practice modifying interview skills to gather data.

Consistently develop appropriate nursing diagnoses.                                             8             2
Prioritize patient health problems based on comprehensive assessment data.                                                44

Establish realistic outcomes.                                                                   26

Copyright WWCC Nursing Department                                                                    Exam Plan/Exam example document
                                          BN3 Emma Goldblum Case B Exam Plan
Objectives                                                                  Version 1                       Version 2     Final
Develop appropriate, specific, creative, individualized nursing interventions (assess, do,    4             39          27
teach).                                                                                       6                         30

Evaluate attainment of outcomes                                                               25            8
Identify modifiable and non-modifiable risk factors for ACS                                   14
Explain the nursing role in health promotion related to risk factors for ACS

Incorporate the concept of “supply and demand” of oxygen into nursing interventions

Incorporate the concept of “supply and demand” of oxygen into nursing internevtions.                        6

Identify diets appropriate for CHF, MI.                                                                     26

Pharmacology                                                                                  27            3           42
Discuss application of nursing principles of pharmacology for safe medication                 28            12          57
administration including action, adverse action, teaching, monitoring, and rationale:         29            13          65
          Oxygen                                                                              30            14          68
         Fibrinolytics                                                                        31            28          73
         Antiplatelet agents                                                                  32            29          74
         Trental                                                                              33            30          75
         Vasopressors                                                                         34            31          76
         Beta Blockers                                                                        35            32          98
         Nitrates                                                                             36            33          100
         Morphine Sulfate                                                                                   34
         Ace Inhibitors/Ace Receptor Blockers                                                               35
         Anti-Cholinergic Parasympatholytic (Atropine)                                                      36
         Antiarrhythmics                                                                                    37
         Calcium Channel Blockers                                                                           50
         Stool Softeners
Pathophysiology                                                                               2             17          19
Integrate pathophysiology with the nursing process in the care of the patient in this case.                 18
Identify the presenting symptoms during the acute phase of an MI.                             3

Explain the mechanism of silent MI

Differentiate how males and females present with MI

Differentiate between stable and unstable angina and an acute MI.

Describe the etiology and pathophysiology of cardiac muscle damage: ischemia, injury,
and infarct.

Differentiate GI and MI symptomology

Explain the dynamics of pre-load, afterload, rate, and contractility                                                    27

Copyright WWCC Nursing Department                                                                  Exam Plan/Exam example document
                                            BN3 Emma Goldblum Case B Exam Plan
Objectives                                                                    Version 1                    Version 2       Final
Describe the etiology, pathophysiology, clinical manifestations, nursing and collaborative   5             4
care of common dysrhythmias:                                                                 41            42
       Tachy, Brady, PVC, V-Tach, V-fib, BBB, asystole, a-fib, and a-flutter                 43            44
                                                                                             45            49

Differentiate between normal and abnormal ejection fraction.

Describe the basic preoperative and basic postoperative management of the patient who        7             10          3
has cardiac surgery.

Describe the etiology, pathophysiology, clinical manifestations, and collaborative care of   12            15          49
the patient with peripheral arterial disease                                                 13            16          50
                                                                                             16            45
                                                                                             44            46
Differentiate left and right sided heart failure; diastolic/systolic heart failure.          48            40          26
                                                                                             49            41          29
Explain the relationship between heart failure and pulmonary edema                           37            47
Discuss the compensatory mechanisms involved in heart failure                                17

Explain Starlings Law and cardiac output

Explain the significance of an S3 heart sound                                                                          53

Interdisciplinary Interventions
Integrate interdisciplinary intervention with nursing interventions by:

Preparing for lab/diagnostic testing                                                         10            11

Caring for patients post procedure                                                                         7

Interpreting lab/diagnostic findings                                                         42            38

               Troponin I, CK-MB, myoglobin, CPK, homocysteine, CRP, Magnesium               38                        51
               BNP, serum chemistries, renal profile, liver profile, CBC                     39                        54
               Holtor monitor
               Nuclear Imaging Studies
               Stress Test

Implementing medical orders

Managing complications                                                                       47            43          18
       Dysrhythmias                                                                                                    52
Hemodynamic instability/cardiogenic shock                                                                  5

Copyright WWCC Nursing Department                                                                 Exam Plan/Exam example document
B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                           Page 1

management of care
1. Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction
(AMI) three days ago is most appropriate for the RN to assign to an experienced LPN/LVN?
*a. administration of the ordered metoprolol (Lopressor) and aspirin
b.    evaluation of the patient’s response to ambulation in the hallway
c.    teaching the patient about the pathophysiology of heart disease
d.    completing the documentation for a home health nurse referral
Rationale: LPN/LVN education and scope of practice include safe administration of medications. Evaluating the patient
response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge
planning/documentation are higher level skills that require RN education and scope of practice.
Mgmt/appl/impl delegation

2. During a visit to an elderly client with chronic heart failure, the nurse finds that the client has severe dependent edema
and that her legs appear to be weeping serous fluid. The nurse prioritizes a nursing diagnosis of
a.    Risk for Impaired Tissue Perfusion related to decreased circulation
b.    Fluid Volume Excess related to heart failure
c.    Activity Intolerance related to edema
*d. Impaired Skin Integrity related to change in fluid status
Rationale: Though all answers may at one time or another be suitable for this client, Impaired Skin Integrity is the priority
problem for this question.
Mgmt/appl/diagnosis CHF

3. A patient with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, which then converts
to a normal sinus rhythm with a heart rate of 98 beats/minute. The most appropriate action by the nurse is to
a.      immediately defibrillate the patient.
*b.     administer antiarrhythmic drugs per protocol.
c.      elevate the head of the bed and administer oxygen at 6 L/min.
d.      continue to monitor the patient's cardiac rhythm without any other interventions at this time.
Rationale: Ventricular tachycardia (VT) is a "run" of PVCs. VT for over 30 seconds is considered sustained and an
ominous sign, especially in a patient with an MI. VT can cause a severe decrease in cardiac output, resulting in shock and
very quickly, death. If the patient is hemodynamically stable, there is no need to immediately defibrillate the patient,
though the nurse should be prepared to perform this procedure. Elevating the head of bed will reduce blood flow to the
heart and brain, worsening the patient's condition. Though this patient is stable at this time, the fact that the patient has an
MI is reason to treat sustained VT with amiodarone or other tolerated antiarrhythmics to prevent the expected
complications of ventricular fibrillation and death.
Mgmt/appl/impl Dysrythmia

4. A client's ECG tracing shows a run of sustained ventricular tachycardia. What is the first action the nurse should take?
*A. Assess the client's airway, breathing, and level of consciousness.
B.     Administer verapamil IV push.
C.     Defibrillate the client.
D.     Begin cardiopulmonary resuscitation.
Rationale: The first action the nurse should take when ventricular tachycardia is observed is to assess the client's airway,
breathing, and level of consciousness. Verapamil is used in atrial arrythmias, defibrillation and initiation of CPR will
depend on the assessment of stability.
Mgmt/appl/impl dysrythmia

5. A client with chest pain is admitted to an emergency room to rule out myocardial infarction. Vital signs are as follows:
at 11:00 am: P 92, R 24, BP 128/82; 11:15 am: P 96, R 26, BP 128/82; 11:30 am: P 104, R 28, BP 104/68; 11:45 am: P
118, R 32, BP 88/58. A nurse alerts the physician because these changes are most consistent with
*a. cardiogenic shock.
b.    cardiac tamponade.
c.    pulmonary embolism.
d.    dissecting thoracic aortic aneurism.
Rationale: Cardiogenic shock occurs with severe damage (>40%) to the left ventricle. Classic signs include hypotension,
rapid pulse that becomes weaker, decreased urine output, cool, clammy skin, and a respiratory rate increase as the body
develops metabolic acidosis.
Mgmt/appl/eval MI

Copyright WWCC Nursing Department                                                            Exam Plan/Exam example document
B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                        Page 2

6. While caring for a patient with angina, the nurse plans interventions that decrease myocardial oxygen demand and
promote coronary blood flow. Appropriate interventions are those that primarily prevent
a.     coronary artery spasm.
*b. an increase in heart rate.
c.     a decreased blood volume.
d.     disruption of circadian rhythms.
Rationale: Myocardial ischemia develops when the coronary arteries are unable to meet the myocardial demand for
oxygen. While coronary artery spasm can cause ischemia, the constriction is transient and reversible. Disruptions in
circadian rhythms can be disturbing, but typically do not increase myocardial oxygen consumption. An increase in heart
rate, or tachycardia, places great demands on the heart and increases oxygen consumption, which can be lethal in a
patient with acute coronary syndromes. Decreased blood volume will elicit the compensatory response of tachycardia,
making this response less global than the correct choice.
Mgmt/appl/impl CAD

7. The client has had angiography with the entrance site in the left femoral artery. Two hours after the procedure, the
nurse is unable to palpate the left pedal pulse. What is the nurse's best action?
A. Elevate the left leg and apply a sandbag to the entrance site.
B. Increase the flow rate of the intravenous fluids.
*C. Notify the physician.
D. Document the finding.
Rationale: Loss of a pulse distal to an angiography entry site may indicate arterial obstruction and the physician should
be notified immediately.
Mgmt/appl/impl angiography

8. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical
manifestation would indicate to the nurse that the client should not yet be advanced to the next level?
A.    facial flushing
*B. onset of chest pain
C.    heart rate increase of ten beats per minute at completion of ambulation
D.    systolic blood pressure increase of 10 mm Hg at completion of ambulation
Rationale: Chest pain on ambulation indicates poor tolerance to activity and is an indication that the heart is not ready for
Mgmt/appl/impl cardiac_rehab

safety - infection control
9. Which of the following statements made by the client with coronary artery disease (CAD) serves to alert the nurse that
the client may be experiencing difficulty in adapting to the illness?
*A. "I usually wait about two hours after I feel chest discomfort before calling my doctor to be sure it is really angina."
B.     "I know I will have some chest discomfort with some activities, so I carry my nitroglycerin with me at all times."
C.     "When I was in the hospital last time for my heart attack, I felt afraid."
D.     "I feel a little anxious whenever I get chest discomfort."
Rationale: Although fear and anxiety are common reactions to CAD, the nurse should stress that denial of symptoms can
result in harm to the client, and such symptoms need to be reported and treatment instituted immediately to avoid
myocardial damage or death.
Psych/appl/assess CAD

10. A nurse is preparing a client to undergo cardiac catheterization. What specific assessment should the nurse make
before the procedure?
A.    Assess the client’s requirement for sedation.
B.    Assess the client’s ability to roll side to side.
C.    Determine if the client has a history of diabetes mellitus.
*D. Determine if the client has allergies to iodine-containing substances.
Rationale: Before the procedure, the nurse should ascertain if the client has an allergy to iodine-containing preparations,
seafood, or local anesthetics. The contrast medium used during the procedure is iodine-based and a local anesthetic will
be used. Patients allergic to seafood may be cross-allergic to iodine-based substances.
Safety/appl/assess PTCA

Copyright WWCC Nursing Department                                                          Exam Plan/Exam example document
B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                          Page 3

11. A transesophageal echocardiogram (TEE) is ordered for a patient to evaluate mitral regurgitation after the patient
survived an MI. Which of these actions included in the standard TEE orders will the nurse need to accomplish first?
*a.      Make the patient NPO.
b.       Start a large-gauge IV line.
c.       Administer O2 per mask.
d.       Give lorazepam (Ativan) 1 mg IV.
Rationale: The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO
status as soon as the order is received. The other actions will also need to be accomplished, but not until just before or
during the procedure.
Safety/appl/impl MI

health promotion and maintenance
12. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin
(Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient
a.       Avoid dietary sources of potassium because too much can cause digitalis toxicity.
b.       Take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min.
c.       Take the hydrochlorothiazide before bedtime to maximize activity level during the day.
*d.      Notify the health care provider immediately if nausea or difficulty breathing occurs.
Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications
are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the provider
can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is potentiated by
hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before taking the digoxin and,
if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to
avoid sleep disruption.
Health/appl/impl CHF

13. The nurse is trying to assess an elderly patient's adherence to his medical treatment plan. Which question about
medication patterns is likely to elicit the most accurate data?
a.    "You always take your digoxin on time, don't you?"
b.    "Why didn't you take all of your Lasix tablets?"
*c.   "It is very common to forget to take your medications once in a while. How many doses would you say you've
missed this past month?"
d.    "You've never missed a dose of your antibiotic, have you?"
Rationale: The correct response is a non-judgmental technique that allows the patient to honestly answer and provide
accurate information.
Health/appl/assess med safety

14. A patient with peripheral arterial disease (PAD) has a new prescription for clopidogrel (Plavix). Which information
should the nurse include when teaching the patient about this medication?
*a. "Call if you notice that your stools are black or have blood in them."
b.     "Take the Plavix on an empty stomach as soon as you get up."
c.     "Change position slowly to avoid dizziness while you are taking Plavix."
d.     "You should never use aspirin while you are taking the Plavix."
Rationale: Clopidogrel inhibits platelet function and increases the risk for GI bleeding. It can be taken without regard to
food. Orthostatic hypotension is not an expected side effect of the medication. Aspirin may be prescribed concurrently
with clopidogrel for some patients.
Health/appl/impl PAD

15. When teaching the patient with peripheral arterial disease (PAD) about modifying risk factors associated with the
condition, the nurse should emphasize
a. amputation is the ultimate outcome if the patient does not alter lifestyle behaviors.
b. risk-reducing behaviors initiated after angioplasty can stop the progression of the disease.
c. maintenance of normal body weight is the most important factor in controlling arterial disease.
*d. modifications will reduce the risk of other atherosclerotic conditions such as coronary heart disease.
Rationale: Peripheral arterial occlusive disease occurs as a result of atherosclerosis and the risk factors are the same as
for other disease associated with atherosclerosis, such as coronary artery disease, cerebral vascular disease, and
aneurysms. Major risk factors are hypertension, cigarette smoking, and hyperlipidemia. The risk of amputation is high in

Copyright WWCC Nursing Department                                                           Exam Plan/Exam example document
B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                           Page 4

patients with server occlusive disease, but mention of this is not the best approach to encourage patients to make lifestyle
modifications. Health/appl/impl PAD
16. A female patient has peripheral arterial disease (PAD) and an exercise program is prescribed for her. In order to
increase the patient's compliance with this treatment regimen, which information should the nurse give to this patient?
A.    "Exercise will increase the strength of the valves in the lower extremity vasculature."
B.    "Exercise is a good way to clear out toxic lactic acid from your system so that you will have less leg pain."
*C. "Exercise will improve collateral circulation in your legs."
D.    "Exercise increases the left ventricular pumping action so that more blood will reach your legs."
Rationale: Exercise can improve arterial blood flow to the affected limb by building collateral circulation. Valves in the
venous return system are not strengthened by exercise, although contraction of the muscles of the lower extremities will
help return venous blood. Exercise produces lactic acid. PAD describes impaired circulation; increasing blood volume is
not the purpose of exercise.
Health/appl/impl PAD

17. The nurse's discharge teaching plan for a client with heart failure would stress the significance of which of the
A.     maintaining a high-fiber diet
B.     walking two miles every day
*C. obtaining daily weights at the same time each day
D.     restricting activity for most of the day
Rationale: A valuable indicator of worsening heart failure is accumulation of body fluid. Daily weights are the best
indicator of systemic fluid volume excess.
Health/appl/plan CHF

18. A client admitted to the hospital with an exacerbation of heart failure tells the nurse that she was fine when she went
to bed but woke up feeling as if she were suffocating. The nurse explains that the onset of these symptoms in the middle
if the night is not unusual because
a.     sleeping causes a decreased heart rate and when the heart slows down it can't meet the oxygen demands of the
b.     lying down decreases the ability of the heart to pump and leads to accumulation of fluid in the lungs.
*c.    lying down promotes fluid reabsorption from areas of peripheral edema and the additional fluid settles in the lungs.
d.     dreaming during sleep increases the heart's need for oxygen and can bring on the symptoms of heart failure.
Rationale: Interstitial fluid returns more readily to the circulatory system when the body is prone or supine. Additionally,
the expanded intravascular volume is more easily returned to the heart, increasing preload. These conditions exacerbate
the pulmonary congestion associated with heart failure and dyspnea is a resulting sign.
Health/appl/impl CHF

psychosocial integrity
19. A few days after experiencing an MI, the patient states, “I just had a little chest pain. As soon as I get out of here, I’m
going for my vacation as planned.” Which nursing intervention is appropriate to include in the nursing care plan?
a.     Have the family members encourage the patient to continue planning for the vacation.
*b. Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI.
c.     Implement reality orientation by reminding the patient several times a day about the MI.
d.     Begin teaching the patient about the normal functions of the heart to improve understanding of the MI.
Rationale: Denial is a normal coping mechanism after an acute episode like an MI; waiting until the patient asks
questions will improve the patient’s ability to take in needed information. The patient should not be encouraged to leave
for a vacation during the MI recovery period. Reminding the patient about the MI is likely to make the patient angry and
lead to distrust of the nursing staff. The patient in denial will not be interested in learning about the normal functions of the
Psych/appl/impl coping

Copyright WWCC Nursing Department                                                            Exam Plan/Exam example document
B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                           Page 5

20. A 68-year-old woman scheduled for coronary artery bypass graft (CABG) for treatment of coronary artery disease is
admitted to the hospital the day before surgery to complete preoperative testing and teaching. She complains to the
nurse that she is tired of being probed and poked and examined so extensively. The most appropriate response by the
nurse to the client is,
a.    "I would think you would be used to all these diagnostic tests by now. You want this surgery, don't you?"
b.    "It is frustrating, I'm sure, but we are trying to get you in the best possible condition before surgery so you won't
have so many problems post-operatively."
c.    "I know you are having lots of tests now honey, but there will be a lot more after the surgery so settle down."
*d. "I can understand your discomfort, it is important for us to know what your current status is so that we can detect
any problems after your surgery."
Rationale: The indicated response acknowledges the patient’s input and forthrightly explains the reasons for the
preoperative workup. Of the two acceptably therapeutic responses, only this is one is accurate because diagnostic testing
does not change the patient’s preoperative condition.
Psych/appl/impl coping

21. A commonly recurring theme faced by the biggest segment of elderly persons is
a.     declining health.
b.     declining financial resources.
c.     inability to maintain independence.
*d. adjustment to losses.
Rationale: Although many elderly will face health, financial, and independence questions, the most universal theme
presented by this question is adjusting to loss. All individuals face losses and these accumulate over time. Even healthy,
financially adjusted independent elderly individuals will suffer the loss of such things as significant others, friends, and
their work-related role.
Psych/appl/assess coping

22. After having an acute myocardial infarction (AMI), a 62-year-old patient tells the nurse, “I guess having sex again will
be too hard on my heart.” The nurse’s best response is,
a.     “Sexual intercourse may be too strenuous on your heart, but closeness and intimacy can be maintained with holding
and cuddling.”
b.     “You should discuss your questions about your sexual activity with your doctor because the activity it requires is a
medical concern.”
c.     “Sexual activity can be resumed whenever you feel like you are ready. Most sexual response is emotional rather
than physical.”
*d. “Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing
two flights of stairs.”
Rationale: Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of
stairs. The answer beginning “Sexual intercourse may be too strenuous” may be true; however there are no data in the
stem to indicate that intercourse will be too stressful to the heart for this patient. The answer beginning, “You should
discuss your questions” implies that there are serious medical concerns about sexual activity. And the answer beginning
“Sexual activity can be resumed whenever” is incorrect because physiologic parameters such as heart rate and BP do
increase during sexual activity.
Psych/appl/impl MI

23. A patient recovering from an MI tells the nurse that he might as well have died when he had the heart attack because
now he will always be a "cardiac cripple." The nursing diagnosis that most clearly identifies the problem expressed in the
patient's comment is
a.     Ineffective Individual Coping related to depression.
*b. Risk for Chronic Low Self-esteem related to perceived role changes.
c.     Impaired Adjustment related to unwillingness to alter lifestyle.
d.     Altered Health Maintenance related to lack of knowledge about cardiac rehabilitation.
Rationale: Anxiety is present in all patients with acute coronary syndromes to some degree. The term "cardiac cripple" is
a term suggesting that cardiac disease has now become a handicap. Because of the gender, age, and developmental
stage of most patients experiencing an MI, their roles in life are frequently perceived to have been affected and this taxes
their self-esteem. Depression is common and is not necessarily ineffective coping at this point. "Cardiac cripple" does
not indicate that a patient is unwilling to alter their lifestyle and it does not indicate a lack of knowledge of cardiac
Copyright WWCC Nursing Department                                                                 Exam Plan/Exam example document
B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                         Page 6

Psych/appl/diag MI

24. An 89-year-old client with chronic heart failure states "I'm a lost cause. I can't even stand long enough to cook my
own meals anymore." An appropriate response from the nurse would be,
*A. "That must be difficult. What things are you still able to do?"
B.    "Well, that's to be expected at your age."
C.    "Do you have someone else who can assist you? Nutrition is very important at your age."
D.    "Did you enjoy cooking?"
Rationale: Validation encourages the client to say more and focuses on the positive. The other options ignore the
emotional component of the client' statement and do not address the client's feelings of valuelessness.
Psych/appl/impl coping

basic care and comfort
25. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a five
pound weight gain in the last three days. The nurse’s first action will be to
a.       ask the patient to recall the dietary intake for the last three days because there may be hidden sources of sodium
in the patient’s diet.
b.       instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive
intake of inappropriate foods.
*c.      assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart
failure may be occurring.
d.       educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to
reduce the hypervolemia.
Rationale: The 5-pound weight gain over three days indicates that the patient’s chronic heart failure may be worsening; it
is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung
crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate
interventions but are not the first nursing actions indicated. There is no evidence that the patient’s weight gain is caused
by excessive dietary intake of fat or calories, so the answer beginning “instruct the patient in a low-calorie, low-fat diet”
describes an inappropriate action.
Basic/appl/assess CHF

26. Which of these patient statements indicates effective teaching about the TLC (Therapeutic Lifestyle Changes) diet by
the nurse?
a.       “I will switch from nonfat milk to whole milk.”
b.       “I like fresh salmon but I can give it up.”
c.       “I will miss being able to eat peanut butter sandwiches.”
*d.      “I can have a cup of coffee with breakfast if I want one.”
Rationale: Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from
monosaturated fats such as are found in nuts, olive oil, and canola oil. Nonfat milk is preferable to whole milk to reduce
overall fat intake. Salmon is an excellent source of omega-3 fatty acids; fish is an appropriate source of protein. The
patient can include peanut butter sandwiches as part of the TLC diet. Coffee is not precluded for a patient using the TLC
Basic/appl/eval nutrition

27. Which of the following data of a client in cardiac rehabilitation provides the best assessment of a client's activity
a.        muscle strength and coordination
*b.       vital signs before, during, and after an activity
c.        vital capacity and breath sounds
d.        degrees of joint flexibility
RATIONALE: Activity tolerance is the body’s capacity to compensate for the physiological stress of activity. Muscle
strength and coordination and joint flexibility determine what types of activity a client may be capable of. Vital capacity
and oxygenation may determine the extent to which a given activity may be accomplished, but the best measurement of a
client’s tolerance for activity will be the change in vital signs induced by the activity.
Basic/appl/assess cardiac rehab

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B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                         Page 7

pharmacology and parenteral therapies
28. You are discussing lab values and medications with a new nurse. You ask the new nurse, "What effects can
moderate to severe hypokalemia have on digoxin therapy?" Which answer do you expect?
a.    “Hypokalemia increases the excretion rate of digoxin; therefore, digoxin must be given twice each day.”
b.    “Hypokalemia increases the half-life of digoxin; therefore, digoxin must be given every other day.”
*c.   “Hypokalemia increases the sensitivity of excitable membranes to digoxin; therefore, toxic effects may occur with
normal doses.”
d.    “Hypokalemia decreases the sensitivity of excitable membranes to digoxin, therefore higher doses of digoxin are
required to achieve a therapeutic effect.”
Rationale: Digoxin exerts its effects by binding to potassium receptor sites on the myocardial membrane. Digoxin
competes with potassium for these receptor sites. When serum potassium levels are below normal, more receptor sites
are available for digoxin, allowing a normal serum level to exert a greater than normal effect.
Pharm/appl/eval chf

29. Which of the following would be the most appropriate time for administering an antilipidemic agent in the clinical
a.     Give the drug in the morning with eight ounces of water.
b.     Give the drug following the breakfast meal.
*c.    Give the drug in the evening.
d.     Let the client determine the timing of the medication according to preference.
Rationale: Cholesterol biosynthesis is higher at night, therefore the blockade by the antilipidemic agent is more effective if
the drugs are administered in the evening.
Pharm/appl/impl CAD

30. Which side effect of the calcium channel blocker nicardipine hydrochloride (Cardene) would be of most concern to the
a.    "My mouth is so dry."
b.    "I haven't had a BM in four days."
c.    BP 200/100
*d. BP 80/50
Rationale: The effect of calcium channel blockers on smooth muscle of both coronary and systemic arteries is to cause
relaxation and relative vasodilation. The primary effects of calcium channel blockers are systemic vasodilation with
decreased SVR, decreased myocardial contractility, and coronary vasodilation. A drop in blood pressure is therefore
expected. However, the nurse must evaluate the expected effects of any drug therapy to determine if a therapeutic
response was obtained. At 80/50, with a MAP of 60, the patient's BP may now be too low, which is an adverse effect.
While many drugs can cause dry mouth and constipation, these are not life-threatening. Hypertension would not be an
expected side effect of calcium channel blockers.
Pharm/appl/eval CHF

31. The nurse should suspect digoxin (Lanoxin) toxicity if a patient states,
a.    "I can't have a BM."
b.    "The lights seem very bright."
*c.   "I have no appetite."
d.    "My blood pressure has been high lately."
Rationale: The common symptoms of digoxin toxicity is anorexia, nausea, and vomiting. The other options are not
related to digitalis toxicity.
Pharm/appl/eval CHF

32. The patient is to continue furosemide (Lasix) 20 mg daily after discharge. The nurse will teach him to
a.    take the medications on an empty stomach.
b.    eat foods high in calcium.
*c.   weigh himself daily and report rapid changes.
d.    take medications in the evening.
Rationale: Due to the diuretic effect, patients should weigh themselves daily and report any rapid changes in weight.
Rapid weight loss indicates loss of fluid which can result in dehydration and hypotension.
Pharm/appl/impl CHF

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B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                           Page 8

33. Dobutamine (Dobutrex) is prescribed for a client with Class II heart failure as a result of an acute myocardial infarction.
What specific response(s) should the nurse expect to see if this therapy is successful?
A.     decreased heart rate, increased pulse quality
B.     decreased heart rate, decreased pulse quality
*C. increased heart rate, increased pulse quality
D.     increased heart rate, decreased pulse quality
Rationale: Dobutamine is a positive inotropic agent that works by stimulating beta-adrenergic receptor sites. The result of
this stimulation is an increase in the rate and force of the myocardial contraction.
Pharm/appl/impl CHF

34. Which of the following statements made by the client with a prescription for sublingual nitroglycerin for chest pain
indicates a need for further discussion regarding this therapy?
*A. "I keep my medicine in a clear plastic bag in my purse so that I can get to it easily if I have chest pain."
B.     "Even if I have not used any of the nitroglycerin from one refill, I get another refill every three months."
C.     "If I still have chest pain after I have taken three nitroglycerin tablets, I will go to the hospital."
D.     "When my nitroglycerin tablet tingles under my tongue, I know that it is strong enough to work."
Rationale: The shelf-life of nitroglycerin is short, and it deteriorates quickly in the presence of light or moisture. A clear
plastic bag does not provide sufficient protection to ensure potency of the drug. Nitroglycerin tablets should be replaced
every three to five months.
Pharm/appl/impl CAD

35. Morphine sulfate 6 mg IV push has been ordered. The drug label reads 10 mg/mL. How many milliliters would the
nurse administer? _______mL.
Answer: 0.6
Rationale: 6mg/x = 10mg/mL. Cross multiply to get 6 = 10x. Divide both sides by 10 to get x=0.6 mL. Remember the
ISMP rule to always place a zero in front of a decimal and use the term "mL" instead of "cc" to reduce medication errors.
Pharm/appl/impl Math

36. On admission to the emergency department, a male patient, age 52, reports severe, crushing, substernal chest pain
that has lasted for one hour. An electrocardiogram reveals an acute inferior wall myocardial infarction (IWMI). Because
the pain persists after the patient receives oxygen, IV nitroglycerin, and IV morphine, his physician prescribes a
thrombolytic agent by IV push. Before administering this fibrinolytic agent, the nurse obtains a thorough history. Which
condition contraindicates the use of fibrinolytic agents?
a.     acute pulmonary thromboembolism
b.     history of previous MI
*c.    cerebrovascular accident in the past two months
d.     age 60 or older
Rationale: Fibrinolytics produce lysis of a pathologic clot but also of other clots. Therefore, patient selection is important
because persons receiving fibrinolytic therapy may have a minor or major bleeding episode as a consequence of therapy.
Therefore, one of the absolute contraindications for fibrinolytic therapy is a history of hemorrhagic stroke and one of the
relative contraindications is stroke or TIA within the past 12 months. Fibrinolytics can actually help an acute pulmonary
thromboembolism, are not withheld in a patient with a previous MI unless the patient has had an allergic reaction to the
fibrinolytic, and age has not been found to be a contraindication for fibrinolytics.
Pharm/appl/assess MI

37. The nurse administers morphine sulfate as ordered to a patient with an acute MI for several reasons, one of which is
because of its ability to
a.    increase myocardial contractility.
b.    increase preload.
c.    increase afterload.
*d. reduce anxiety.
Rationale: Morphine sulfate is given for acute chest pain relief because it reduces anxiety and fear and decreases the
cardiac workload by lowering myocardial oxygen consumption, reducing contractility, lowering BP, and slowing the HR.
Pharm/appl/impl MI

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reduction of risk potential
38. While observing the ECG monitor of a patient admitted to the emergency department with chest pain, the nurse
suspects that the patient is having a myocardial infarction rather than angina upon finding
a.     sinus tachycardia.
b.     an S3 gallop.
*c.    S-T segment elevation.
d.     occasional premature ventricular contractions (PVCs).
Rationale: ST segment elevation greater than one mm above baseline on an ECG indicates myocardial cell infarction,
which is consistent with MI. ST segment depression is consistent with ischemia, which indicates angina. Patients with
ST-segment elevation (STEMI) tend to have a more extensive MI. Sinus tachycardia is a HR greater than 100 beats per
minute but can come from a multitude of reasons and is not life-threatening. An S3 gallop is an extra heart sound heard
when there is a problem with ventricular filling and fluid overload, as in heart failure as well as MIs and other acute
coronary syndromes. Occasional PVCs commonly occur in people when they are stressed, fatigued, or have too much
caffeine, but can be very concerning in the patient experiencing an MI.
Risk/appl/assess MI

From V1
39. A patient with peripheral vascular disease has marked peripheral neuropathy. Which of the following is an appropriate
nursing diagnosis for this patient?
*a.     Risk for Injury related to decreased sensation
b.      Impaired Skin Integrity related to decreased peripheral circulation
c.      Ineffective l Tissue Perfusion related to decreased arterial blood flow
d.      Activity Intolerance related to imbalance between oxygen supply and demand
Rationale: Diminished blood perfusion to nerve tissue cells produces a neuropathy manifested by loss of both sensations
and deep pain, and injuries to the extremity often go unnoticed. It is important to teach the patient to protect the feet and
detect and prevent injuries to prevent breaks in the skin that can lead to infection and gangrene.
Risk/appl/diag PAD

40. Which of the following signs or symptoms are manifestations of left ventricular failure? (Select all that apply.)
*A. oliguria
*B. dyspnea
C.     bradycardia
*D. fatigue
E.     peripheral edema
Rationale: As the left ventricle fails, blood backs up into the pulmonary circulation resulting in dyspnea. Fatigue and
oliguria indicate poor cardiac output, a result of left ventricular failure. Tachycardia, rather than bradycardia, is a
compensatory response to poor cardiac output. Peripheral edema is a hallmark of right ventricular failure.
Risk/appl/assess chf

41. A patient has right ventricular failure. The nurse should expect which of the following symptoms?
A.    oliguria
*B. jugular venous distention
C.    pulmonary edema
D.    dry, hacky cough
Rationale: A failing right ventricle is unable to empty completely. This results in increased volume and pressure in the
venous system, visible as jugular venous distension and peripheral edema.
Risk/appl/assess CHF

42. A client has consistent and regular slow heart rate, averaging 56 beats per minute. The client has no adverse
symptoms associated with this bradycardia and is not being treated for it. Which of the following activity modifications
should the nurse suggest to avoid further slowing of the heart rate?
A.    "Make certain that your bath water is warm (100°F)."
*B. "Avoid bearing down or straining while having a bowel movement."
C.    "Avoid strenuous exercise, such as running, during the late afternoon."
D.    "Limit your intake of caffeinated drinks to no more than two cups per day."
Rationale: Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the
vagus nerve and results in a slowing of heart rate. Such a response is not desirable in a person who has bradycardia.
Risk/appl/assess dysrythmia

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B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                        Page 10

43. Which of the following symptoms experienced by a patient following an acute MI will most likely be relieved by oxygen
a.    metabolic alkalosis and an elevated CK-MB
*b. dysrhythmia and related hypotension
c.    sweating and hyperoxemia
d.    hypertension and AV conduction problems
Rationale: Oxygen therapy is important to the prevention and treatment of life-threatening dysrhythmias, which occur
often as a result of myocardial ischemia. The ineffective contraction of the heart may result in reduced cardiac output and
poor perfusion, leading to hypotension. Acid-base and cardiac enzyme abnormalities do not specifically resolve with O2
administration. Hyperoxemia would not require additional oxygen. Hypertension is not expected with an MI and
conduction defects are due to damage to the conduction system and do not respond to O2.
Risk/appl/assess dysrythmia

physiological adaptation
44. A nurse is caring for a client four days post myocardial infarction (MI). The patient’s cardiac monitor displays
premature ventricular contractions (PVCs) at the rate of five per minute. What other dysrhythmia may develop as a result
of this?
A. sinus tachycardia
B. rapid atrial flutter
*C. ventricular tachycardia
D. atrioventricular junctional rhythm
Rationale: After acute MI, PVCs may herald the onset of ventricular tachycardia.
Physio/appl/eval dysrythmia

45. A client complains of claudication after walking a distance of one block. A nurse notes that the client has developed a
painful ulcer on the toes of the right foot. Which condition is most likely responsible for this client's symptoms?
A.    diabetic foot ulceration
*B. peripheral arterial disease
C.    peripheral venous disease
D.    necrosis or gangrene of the toes
Rationale: Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by
peripheral arterial disease are painful and initially located at the most distal points on the extremity. Diabetic ulcers and
venous ulcers are seldom painful and usually tend to occur where pressure is applied.
Physio/appl/eval PAD

46. Which statement made by the client with peripheral arterial disease concerning positioning of edematous lower
extremities requires further clarification?
A. "I may sleep with my affected leg hanging from the bed."
*B. "I will elevate my legs above the level of my heart."
C. "I can sit upright in a chair for comfort."
D. "I will avoid crossing my legs."
Rationale: Extreme elevation of edematous legs can actually slow arterial blood flow to the feet, so this positioning should
be avoided. The client may sleep with the affected limb hanging or positioned upright in a chair for further comfort. The
client is also instructed to avoid crossing the legs, because this interferes with blood flow.
Physio/appl/eval PAD

47. Which conditions describe how pulmonary edema begins in a client who has left-sided heart failure?
a.     increased blood volume in pulmonary vessels causes increased blood osmotic pressure
b.     increased blood volume in pulmonary vessels causes decreased blood osmotic pressure
*c.    increased blood volume in pulmonary vessels causes increased blood hydrostatic pressure
d.     increased blood volume in pulmonary vessels causes decreased blood hydrostatic pressure
Rationale: As the left ventricle fails, less blood is moved from the left ventricle into the aorta. Blood eventually backs up
into the left atrium and then into the pulmonary vessels. This increased volume in the pulmonary vessels increases the
hydrostatic pressure, forcing fluid from the pulmonary vessels into the pulmonary interstitial tissues.
Physio/appl/eval CHF

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B-Nursing III (NRST 2630), Emma Goldbum Case D Exam_V2 (rev. 10/31/08/kl&db)                                          Page 11

48. Which of the following clinical manifestations indicates activity intolerance when a client is being tested for heart failure
by progressively increased activity?
a.    oxygen saturation of 95%
b.    respiratory rate of 26 breaths/min
*c.   systolic blood pressure change from 136 to 96 mm Hg
d.    heart rate increase from 86 to 110 beats/min
Rationale: A blood pressure change (increase of decrease) of more than 20 mm Hg during or after activity indicates poor
cardiac tolerance of the activity. A significant decrease in blood pressure during or following activity is especially
ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.
Physio/appl/eval CHF

49. A 19-year-old student has a mandatory ECG before participating on a college swim team and is found to have sinus
bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate?
a.       Refer the student to a cardiologist for further assessment.
*b.      Allow the student to participate on the swim team.
c.       Obtain more detailed information about the student’s health history.
d.       Tell the student to stop swimming immediately if any dyspnea occurs.
Rationale: In an aerobically trained individual, sinus bradycardia is normal. The student’s normal BP and negative health
history indicate that there is no need for a cardiology referral or for more detailed information about the health history.
Dyspnea during an aerobic activity such as swimming is normal.
Physio/appl/impl dysrythmia

50.      A patient with myocardial infarction develops symptomatic hypotension. The monitor shows a type 1, second-
degree AV block with a heart rate of 30. The nurse administers IV atropine as prescribed. The nurse determines that the
drug has been effective on finding a(n)
*a.      increase in the patient’s heart rate.
b.       increase in peripheral pulse volume.
c.       decrease in ventricular response.
d.       decrease in premature contractions.
Rationale: Atropine will increase the heart rate and conduction through the AV node. Because the medication increases
electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug
effectiveness. Ventricular response will be increased by atropine because of the improvement in AV conduction. Atropine
will not decrease PVCs, and the patient does not have PVCs.
Physio/appl/evaluation dysrythmia

Exam Plan
 Mgmt     Safety          HP        Psycho       Basic      Pharm        RP      Physio     Math
  7-10     4-7            3-6         3-6         3-6         10        7-10      6-9        1
 V1 8       3              7           5           3          10          7        7         1
 V2 8       3              7           6           3          10          6        7         1

              Content                        Version 1     Version 2
              Mi                             7             7
              PCI/angiography                2             2
              Cardiac rehab                  1             2
              PAD                            6             6
              CHF                            14            14
              Dysrthymia                     7             7
              CAD                            3             4
              Lpn assignment                 1             1
              Nutrition                      1             1
              Medication safety              2             1
              Communication/coping           5             4
              Math                           1             1

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