NCLEX - PN Review –
CARDIOVASCULAR questions well
answered
the nurse is assigned to assist with caring for a client after cardiac catheterization.
the nurse should plan to maintain bed rest for this client in which position?
a) high-Fowler's position
b) lateral (side-lying) position
c) head elevation of 45 degrees
d) head elevation of no more than 30 degrees - correct answer ✔✔d) head elevated of no more than 30
degrees
rationale
after cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the
prescribed time period.
the client may turn from side to side.
the client is placed in the supine position and the head of the bed is not elevated to more than 30
degrees to keep the affected leg straight at the grain and prevent arterial occlusion.
bathroom privileges are not allowed during the immediate postcatheterization period.
for the high-fowler's position, the head of the bed is elevated 90 degrees.
a postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dl and a serum creatinine
level of 2.2 mg/dl has a total 2-hour urine output of 25 ml.
the nurse understands that the client is at risk for which?
,a) hypovolemia
b) acute kidney injury
c) glomerulonephritis
d) urinary tract infection - correct answer ✔✔b) acute kidney injury
rationale
the client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion,
hemolysis, low cardiac output, or vasopressor medication therapy.
kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels.
the client may need medications to increase renal perfusion and could need peritoneal dialysis or
hemodialysis.
the nurse is preparing to ambulate a postoperative client after cardiac surgery.
the nurse plans to do which to enable the client to best tolerate the ambulation?
a) provide the client with a walker
b) remove the telemetry equipment
c) encourage the client to cough and deep breathe
d) premedicate the client with an analgesic before ambulating - correct answer ✔✔d) premedicate the
client with an analgesic before ambulating
rationale
,the nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac
surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain,
and allow better participation in activities such as coughing, deep breathing and ambulation.
a client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station.
the nurse sees no electrocardiographic complexes on the screen.
the nurse should do which first?
a) call a code blue
b) call the HCP
c) check the client status and lead placement
d) press the recorder button the ECG console - correct answer ✔✔c) check the client status and lead
placement
rationale
sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode
displacement.
checking of the client and equipment is the first action by the nurse.
the nurse in a medical unit is caring for a client with heart failure.
the client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects
pulmonary edema.
the nurse immediately notifies the RN and expects which interventions to be prescribed?
select all that apply
administering oxygen
, inserting a Foley catheter
administering forosemide (lasix)
administering morphine sulfate intravenously
transporting the client to the CCU
placing the client in a low-Fowler's side-lying position - correct answer ✔✔administering oxygen //
inserting a Foley catheter // administering furosemide (Lasix) // administering morphine sulfate
intravenously
rationale
pulmonary edema is a life-threatening event that can result from severe heart failure.
in pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs
because of the accumulated blood.
oxygen is always prescribed, and the client is placed in a high-fowler's position to ease the work of
breathing.
Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid.
a foley catheter is inserted to accurately measure output.
intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and
reduces the work of breathing.
transporting the client to the CCU is not a priority intervention.
in fact, this may not be necessary at all if the client's response to treatment is successful.
the nurse is monitoring a client following cardioversion.
which observation should be of highest priority to the nurse?
a) blood pressure
CARDIOVASCULAR questions well
answered
the nurse is assigned to assist with caring for a client after cardiac catheterization.
the nurse should plan to maintain bed rest for this client in which position?
a) high-Fowler's position
b) lateral (side-lying) position
c) head elevation of 45 degrees
d) head elevation of no more than 30 degrees - correct answer ✔✔d) head elevated of no more than 30
degrees
rationale
after cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the
prescribed time period.
the client may turn from side to side.
the client is placed in the supine position and the head of the bed is not elevated to more than 30
degrees to keep the affected leg straight at the grain and prevent arterial occlusion.
bathroom privileges are not allowed during the immediate postcatheterization period.
for the high-fowler's position, the head of the bed is elevated 90 degrees.
a postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dl and a serum creatinine
level of 2.2 mg/dl has a total 2-hour urine output of 25 ml.
the nurse understands that the client is at risk for which?
,a) hypovolemia
b) acute kidney injury
c) glomerulonephritis
d) urinary tract infection - correct answer ✔✔b) acute kidney injury
rationale
the client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion,
hemolysis, low cardiac output, or vasopressor medication therapy.
kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels.
the client may need medications to increase renal perfusion and could need peritoneal dialysis or
hemodialysis.
the nurse is preparing to ambulate a postoperative client after cardiac surgery.
the nurse plans to do which to enable the client to best tolerate the ambulation?
a) provide the client with a walker
b) remove the telemetry equipment
c) encourage the client to cough and deep breathe
d) premedicate the client with an analgesic before ambulating - correct answer ✔✔d) premedicate the
client with an analgesic before ambulating
rationale
,the nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac
surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain,
and allow better participation in activities such as coughing, deep breathing and ambulation.
a client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station.
the nurse sees no electrocardiographic complexes on the screen.
the nurse should do which first?
a) call a code blue
b) call the HCP
c) check the client status and lead placement
d) press the recorder button the ECG console - correct answer ✔✔c) check the client status and lead
placement
rationale
sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode
displacement.
checking of the client and equipment is the first action by the nurse.
the nurse in a medical unit is caring for a client with heart failure.
the client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects
pulmonary edema.
the nurse immediately notifies the RN and expects which interventions to be prescribed?
select all that apply
administering oxygen
, inserting a Foley catheter
administering forosemide (lasix)
administering morphine sulfate intravenously
transporting the client to the CCU
placing the client in a low-Fowler's side-lying position - correct answer ✔✔administering oxygen //
inserting a Foley catheter // administering furosemide (Lasix) // administering morphine sulfate
intravenously
rationale
pulmonary edema is a life-threatening event that can result from severe heart failure.
in pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs
because of the accumulated blood.
oxygen is always prescribed, and the client is placed in a high-fowler's position to ease the work of
breathing.
Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid.
a foley catheter is inserted to accurately measure output.
intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and
reduces the work of breathing.
transporting the client to the CCU is not a priority intervention.
in fact, this may not be necessary at all if the client's response to treatment is successful.
the nurse is monitoring a client following cardioversion.
which observation should be of highest priority to the nurse?
a) blood pressure
