Lewis Med-Surg 12th Edition — Master the Cardiovascular Unit & Pass Every Exam (Ch. 31–37)

The cardiovascular unit is the make-or-break chapter sequence of every Lewis Medical-Surgical Nursing course. Chapters 31 through 37 cover the widest range of conditions, carry the most exam weight in every US nursing program that teaches from Lewis, and represent the single largest content area on the NCLEX. Students who master this unit ace their med-surg exams. Students who don't carry the deficit all the way to NCLEX.

This guide covers every chapter in the Lewis 12th Edition cardiovascular unit — what each chapter tests, the clinical reasoning patterns your professor is looking for, the questions students most commonly get wrong and why, and the practice questions that build the automatic thinking this unit requires.

Ch 31–377 cardiovascular
chapters in Lewis 12e

#1Most tested unit
in Lewis courses

26–38%Of NCLEX questions —
physiological integrity

$15.99Full Lewis 12e
test bank PDF

❤️ Why this unit matters more than any other: Cardiovascular conditions are the leading cause of death in the United States. Every nursing professor knows this — which is why Lewis Chapters 31–37 consistently carry more exam questions, more clinical scenario weight, and more NCLEX representation than any other unit. You cannot afford to treat this as just another chapter sequence.

Chapter by Chapter — Lewis Cardiovascular Unit Breakdown

Ch. 31

Assessment of the Cardiovascular System

High Yield

The foundation chapter — everything in chapters 32–37 builds on the assessment skills here. Questions test cardiac auscultation landmarks, normal vs. abnormal heart sounds (S1, S2, S3, S4, murmurs), hemodynamic monitoring basics, and interpreting cardiac biomarkers (troponin, BNP, CK-MB).

Cardiac biomarkers — troponin I & T BNP interpretation Heart sound auscultation Hemodynamic monitoring 12-lead ECG basics JVD assessment

What professors love to test: The difference between troponin (myocardial injury-specific) and CK-MB (less specific), and what an elevated BNP indicates clinically — heart failure with fluid overload.

Ch. 32

Hypertension

High Yield

Hypertension questions focus on medication management, patient teaching, and hypertensive crisis nursing priorities. The most common Lewis Chapter 32 exam trap: students select "start antihypertensives immediately" without checking for contraindications or current BP reading context.

Hypertensive urgency vs. crisis ACE inhibitors — contraindications DASH diet patient teaching Medication side effects (ACEi cough, beta blocker fatigue) BP monitoring and lifestyle modifications

Ch. 33

Coronary Artery Disease & Acute Coronary Syndrome

🔥 #1 Most Tested

Chapter 33 is the single most heavily tested chapter in the entire Lewis textbook across US nursing programs. ACS questions test whether students can differentiate unstable angina vs. NSTEMI vs. STEMI, apply the MONA framework correctly, interpret troponin trends, and identify nursing priorities before and after PCI. Every Lewis med-surg exam will have multiple Chapter 33 questions.

STEMI vs NSTEMI differentiation Troponin I — timing of rise & peak tPA eligibility criteria MONA — aspirin FIRST PCI pre/post care Nitroglycerin — hold if BP <90 systolic Unstable angina priority actions Post-MI patient education

The question every Lewis professor writes: A patient with chest pain arrives in the ED. What is the nurse's FIRST action? Answer: Give aspirin 325mg chewed — before anything else that doesn't involve airway.

Lewis Chapter 33 — ACS Priority (Most Missed)

Clinical scenario: A 58-year-old male arrives to the ED with crushing substernal chest pain radiating to his left arm, rated 9/10, that began 45 minutes ago. Diaphoresis is present. BP 148/92, HR 98, RR 18, SpO2 96% on room air. 12-lead ECG shows ST elevation in leads II, III, and aVF.

Which nursing action is the highest priority?

A. Apply supplemental oxygen at 4 L/min via nasal cannula
B. Administer aspirin 325 mg orally — chewed, not swallowed whole
C. Administer sublingual nitroglycerin 0.4 mg as ordered
D. Obtain a second set of cardiac biomarkers to confirm STEMI

Correct: B — Aspirin first. In acute STEMI, aspirin is the first-line antiplatelet intervention and should be given immediately — before oxygen (SpO2 96% is adequate, O2 only indicated if SpO2 <94%), before nitroglycerin (which requires BP check first and should come after aspirin), and before waiting for a second troponin. Chewing aspirin produces faster absorption than swallowing. The inferior wall STEMI (ST elevation in II, III, aVF) means right coronary artery involvement — which also creates risk with nitroglycerin if right ventricular infarction is present. ⚠️ Why C is a trap: Nitroglycerin requires confirming BP ≥90 systolic AND ruling out PDE5 inhibitor use within 24–48h. Aspirin has no such prerequisite and comes first in the MONA framework.

Ch. 34

Heart Failure

🔥 Most NCLEX Questions

Heart failure generates more NCLEX questions than almost any other chapter in Lewis — and it's also the most nuanced. Students must differentiate left-sided vs. right-sided HF manifestations, understand the pathophysiology behind each sign (why crackles in left HF, why peripheral edema in right HF), and prioritize nursing actions for acute decompensation correctly. The ABCs framework is critical here: SpO2 and respiratory distress are addressed before medication management.

Left vs. right HF differentiation BNP — elevated = HF fluid overload SpO2 <90% → O2 + HOB elevation FIRST Digoxin — therapeutic range 0.5–2 ng/mL Furosemide — monitor K+ loss Daily weights — call HCP if +2 lbs in 24h or +5 in a week Fluid restriction and sodium restriction teaching Pulmonary edema — tripod position, O2, morphine prn

Lewis Chapter 34 — Heart Failure Assessment

Clinical scenario: A patient with chronic heart failure is admitted for acute decompensation. Assessment: SpO2 86% on room air, RR 28, bilateral crackles to mid-lung fields, 3+ pitting edema bilateral lower extremities, weight gain of 7 lbs in 4 days, JVD present. The patient is anxious and using accessory muscles to breathe.

The nurse places the patient in high Fowler's position and applies supplemental oxygen. Which action should the nurse take next?

A. Administer the scheduled oral furosemide dose
B. Notify the healthcare provider immediately of the patient's current status
C. Weigh the patient to assess for additional fluid gain since admission
D. Restrict oral fluids to 500 mL for the remainder of the shift

Correct: B — Notify the HCP. The nurse has already initiated the two immediate independent nursing actions (HOB elevation + O2). With SpO2 86%, RR 28, accessory muscle use, and acute decompensation — this patient requires urgent physician assessment and likely IV diuretics, not oral furosemide which acts slowly. Notifying the HCP is the next priority to escalate care appropriately. ⚠️ Why A is a trap: Oral furosemide has delayed onset and is inappropriate for acute decompensation with SpO2 86%. IV furosemide with HCP order is what this patient needs — you can't give that without first notifying the provider.

Ch. 35

Dysrhythmias

🔥 Top Priority

Dysrhythmia questions test rhythm recognition and priority intervention. Students don't need to be ECG experts — they need to know which rhythms are immediately life-threatening (V-fib → defibrillate NOW, V-tach with no pulse → CPR, A-fib → anticoagulation risk), which require urgent intervention, and which can be monitored. The NCLEX never asks you to read a 12-lead — it asks you what the nurse does about the rhythm.

V-fib → defibrillate immediately Pulseless V-tach → CPR + defibrillate A-fib → stroke risk → anticoagulation Digoxin toxicity → bradycardia, AV block Pacemaker care — activity restrictions Amiodarone — lung/thyroid/liver toxicity monitoring Cardioversion vs. defibrillation distinction

Lewis Chapter 35 — Dysrhythmia Priority

A nurse is monitoring a patient on telemetry when the monitor suddenly shows a chaotic, irregular rhythm with no identifiable P waves, QRS complexes, or T waves. The patient is unresponsive and has no palpable pulse. What is the nurse's immediate action?

A. Call the healthcare provider and await orders
B. Administer amiodarone 300 mg IV push as per standing orders
C. Call for help, begin CPR, and prepare the defibrillator immediately
D. Perform synchronized cardioversion at 200 joules

Correct: C — CPR + defibrillator. The described rhythm is ventricular fibrillation (V-fib) — a lethal dysrhythmia requiring immediate CPR and unsynchronized defibrillation. Every minute without defibrillation reduces survival by 7–10%. Call for help first (activate code), begin CPR, and charge the defibrillator. ⚠️ Why D is wrong: Synchronized cardioversion is for rhythms with organized electrical activity (A-fib, SVT, V-tach WITH a pulse). V-fib has NO organized activity — synchronization cannot detect an R wave to fire on. Unsynchronized defibrillation is required.

Ch. 36–37

Inflammatory Cardiac Disorders & Vascular Problems

High Yield

Chapter 36 covers endocarditis, myocarditis, pericarditis, and rheumatic fever — conditions students confuse because they all involve cardiac inflammation but with different mechanisms, treatments, and nursing priorities. Chapter 37 covers peripheral arterial disease (PAD) vs. deep vein thrombosis (DVT) — a classic comparison question that appears on virtually every Lewis cardiovascular exam.

PAD vs DVT — key differences Endocarditis — IV antibiotics 4–6 weeks Pericarditis — pericardial friction rub, leaning forward relieves pain DVT — Homan's sign unreliable, compression stockings, anticoagulation PAD — intermittent claudication, dependent positioning helps Rheumatic fever — strep prevention, penicillin prophylaxis

Lewis Chapter 37 — PAD vs. DVT (Classic Trap)

A nurse is assessing two patients. Patient A has leg pain that worsens with walking and improves with rest, cool pale skin, and absent pedal pulses. Patient B has unilateral calf swelling, warmth, and redness that developed after a long flight. Which statement correctly differentiates these two conditions?

A. Patient A has DVT — the absent pulses indicate venous occlusion
B. Patient B has PAD — the warmth indicates arterial insufficiency
C. Patient A has peripheral arterial disease; Patient B has deep vein thrombosis
D. Both patients have DVT — both require immediate anticoagulation

Correct: C. Patient A has PAD: intermittent claudication (pain with walking, relieved by rest), cool pale skin, absent pedal pulses = arterial insufficiency. Positioning: legs dependent improves arterial flow. Patient B has DVT: unilateral swelling, warmth, redness after prolonged immobility = venous thrombosis. DVT: elevate leg, anticoagulate. PAD: never elevate (reduces arterial perfusion), keep dependent. Confusing these leads to dangerous nursing errors — this distinction is a Lewis exam and NCLEX staple. ⚠️ Critical nursing safety: Elevating the leg of a PAD patient REDUCES blood flow and worsens ischemia. Elevating the leg of a DVT patient REDUCES swelling and prevents clot extension. The interventions are opposite — misidentifying the condition causes harm.

The 7 Most Missed Lewis Cardiovascular Exam Questions — And Why

Giving O2 first in MI instead of aspirin

SpO2 96% in an MI patient does not need oxygen. Current guidelines reserve O2 for SpO2 <94%. Aspirin comes first — it's the immediate antiplatelet action with no prerequisites.

→ Framework: MONA — Morphine, Oxygen (only if hypoxic), Nitroglycerin (check BP first), Aspirin (always first)

Giving oral furosemide for acute HF decompensation

Oral furosemide takes 30–60 minutes to act and is inappropriate when a patient has SpO2 86% and accessory muscle use. Acute decompensation requires IV intervention — which requires notifying the HCP first.

→ Rule: Oral medications = maintenance. IV medications = acute. Know which situation you're in.

Using synchronized cardioversion for V-fib

Synchronized cardioversion requires an organized rhythm with detectable R waves. V-fib has none — the device cannot synchronize. Unsynchronized defibrillation is always correct for V-fib and pulseless V-tach.

→ Rule: Pulse present + organized rhythm → cardioversion. Pulseless or V-fib → defibrillation (unsynchronized).

Elevating legs for a PAD patient

Elevating legs is appropriate for DVT (reduces venous swelling) but dangerous for PAD (reduces arterial flow to already ischemic tissue). Lewis Chapter 37 tests this comparison consistently.

→ PAD: keep legs dependent, warm environment. DVT: elevate legs, anticoagulate, no massage.

Giving nitroglycerin without checking BP first

Nitroglycerin is a vasodilator — giving it when systolic BP <90 mmHg causes severe hypotension. Always check BP before each nitroglycerin dose. Hold and notify HCP if systolic <90.

→ Before every nitroglycerin dose: BP check. <90 systolic = hold. Also hold if patient took sildenafil/tadalafil in last 24–48h.

Confusing left HF and right HF manifestations

Left HF → fluid backs up into the lungs → crackles, dyspnea, orthopnea, low SpO2. Right HF → fluid backs up into systemic circulation → JVD, peripheral edema, hepatomegaly, ascites. Most HF patients have both but the distinction is tested.

→ Left HF = pulmonary symptoms. Right HF = systemic symptoms. Most real HF patients have both.

Misinterpreting BNP and troponin results

BNP elevated = heart failure (ventricular wall stress from fluid overload). Troponin elevated = myocardial cell death (MI). Students mix these up on Lewis Chapter 31 and 34 questions that present both values together.

→ Troponin = heart muscle death (MI marker). BNP = heart wall stretch (HF marker). Two different problems, two different markers.

High-Yield Drug Table — Lewis Cardiovascular Medications

Drug / Class	Chapter	Key NCLEX Nursing Point
Aspirin 325mg	Ch. 33	Give chewed immediately in ACS — no prerequisites
Nitroglycerin SL	Ch. 33	Hold if BP <90 systolic; max 3 doses q5min; no PDE5i use
Furosemide (Lasix)	Ch. 34	Monitor K+ (hypokalemia risk); weigh daily; I&O
Digoxin	Ch. 34	Therapeutic 0.5–2 ng/mL; toxicity → bradycardia, visual changes, N/V; check apical pulse 1 min before giving
ACE Inhibitors (-pril)	Ch. 32/34	Dry cough = common side effect; contraindicated in pregnancy; monitor K+ and creatinine
Beta Blockers (-olol)	Ch. 32/34	Do NOT stop abruptly; mask hypoglycemia signs; check HR before giving (hold if <60)
Amiodarone	Ch. 35	Monitor: pulmonary toxicity (cough, dyspnea), thyroid dysfunction, liver enzymes, corneal deposits, photosensitivity
Warfarin	Ch. 37	Therapeutic INR 2–3 for DVT/A-fib; monitor INR; antidote = Vitamin K
Heparin IV	Ch. 37	Monitor aPTT q6h; therapeutic 60–100 sec; antidote = protamine sulfate; watch for HIT

Your Cardiovascular Exam Study Plan — Lewis 12th Edition

Days 1–2

Chapter 31 — Assessment foundation (30 questions)

Work all assessment chapter questions before anything else. If you can't interpret a BNP or troponin correctly, cardiac diagnosis questions in Ch. 33–34 will be harder to answer accurately.

Days 3–4

Chapter 33 — ACS deep dive (50 questions minimum)

This is the most tested chapter. Do not move on until you can correctly apply MONA, differentiate STEMI vs NSTEMI, and identify when NOT to give nitroglycerin. These patterns must be automatic.

Days 5–6

Chapter 34 — Heart failure (50 questions)

Left vs. right HF, acute decompensation priorities, digoxin and furosemide management. This chapter generates the most NCLEX questions — treat it like a second exam in itself.

Day 7

Chapter 35 + 37 — Dysrhythmias & Vascular (40 questions each)

Rhythm recognition and intervention priorities for Ch. 35. PAD vs DVT differentials and anticoagulation for Ch. 37. Both chapters have signature "most missed" question types — practice both until the patterns are clear.

Exam Week

Error log review — your personal weak spots only

Go back to every question you got wrong and re-read the rationale. No new chapters. No re-reading notes. Only targeted practice on your confirmed weak areas from the previous 7 days.

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Q: How many questions should I do per Lewis cardiac chapter before my exam?

Minimum 40 questions for Ch. 32 (Hypertension) and Ch. 36–37 (Inflammatory/Vascular). Minimum 60 questions for Ch. 33 (ACS) and Ch. 34 (Heart Failure) — these two chapters are exam-defining. For Ch. 35 (Dysrhythmias), 40–50 questions with heavy focus on rhythm-to-intervention mapping. Total for the full cardiovascular unit: 250–350 questions over 7–10 days before your exam.

Q: My Lewis exam is in 3 days — where do I focus?

Three days out: Day 1 → 60 questions Ch. 33 (ACS) only, read every rationale. Day 2 → 60 questions Ch. 34 (HF) only, read every rationale. Day 3 → 30 questions Ch. 35 (Dysrhythmias) + review your error log from the previous two days. Do not try to cover all 7 chapters in 3 days — prioritize the two highest-yield chapters and master them completely.

Q: Does the Lewis cardiovascular content transfer to NCLEX prep?

Directly and significantly. Cardiovascular conditions (heart failure, ACS, dysrhythmias, hypertension, PAD/DVT) account for a substantial portion of NCLEX physiological integrity questions — the largest single NCLEX category. Students who master Lewis cardiovascular during their course consistently find these NCLEX questions the most manageable. The clinical reasoning patterns are identical.