SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
1. A client admitted to the hospi- Metformin
tal with chest pain and a his-
tory of type 2 diabetes mel- Metformin needs to be withheld 24 hours
litus is scheduled for cardiac before and for 48 hours after cardiac
catheterization. Which medica- catheterization because of the injection of
tion would need to be withheld contrast medium during the procedure. If
for 24 hours before the proce- the contrast medium affects kidney func-
dure and for 48 hours after the tion, with metformin in the system the client
procedure? would be at increased risk for lactic acido-
sis. The medications in the remaining op-
tions do not need to be withheld 24 hours
1. before and 48 hours after cardiac catheter-
Glipizide ization.
2.
Metformin
3.
Repaglinide
4.
Regular insulin
2. A client who had cardiac Acute kidney injury
surgery 24 hours ago has had
a urine output averaging 20 The client who undergoes cardiac surgery
mL/hour for 2 hours. The client is at risk for renal injury from poor per-
received a single bolus of 500 fusion, hemolysis, low cardiac output, or
mL of intravenous fluid. Urine vasopressor medication therapy. Renal in-
output for the subsequent hour jury is signaled by decreased urine out-
was 25 mL. Daily laboratory re- put and increased blood urea nitrogen
sults indicate that the blood (BUN) and creatinine levels. Normal ref-
urea nitrogen level is 45 mg/dL erence levels are BUN, 10-20 mg/dL
(16 mmol/L) and the serum (3.6-7.1 mmol/L), and creatinine, male,
creatinine level is 2.2 mg/dL 0.6-1.2 mg/dL (53-106 mcmol/L) and fe-
(194 mcmol/L). On the basis male 0.5-1.1 mg/dL (44-97 mcmol/L). The
of these findings, the nurse client may need medications to increase
would anticipate that the client renal perfusion and possibly could need
is at risk for which problem? peritoneal dialysis or hemodialysis. No
data in the question indicate the presence
1. of hypovolemia, glomerulonephritis, or uri-
Hypovolemia nary tract infection.
, SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
2.
Acute kidney injury
3.
Glomerulonephritis
4.
Urinary tract infection
3. The nurse is reviewing an elec- Continue to monitor for any rhythm
trocardiogram rhythm strip. change.
The P waves and QRS com-
plexes are regular. The PR in- Normal sinus rhythm is defined as a reg-
terval is 0.16 seconds, and ular rhythm, with an overall rate of 60
QRS complexes measure 0.06 to 100 beats/minute. The PR and QRS
seconds. The overall heart rate measurements are normal, measuring be-
is 64 beats/minute. Which ac- tween 0.12 and 0.20 seconds and 0.04
tion should the nurse take? and 0.10 seconds, respectively. There are
no irregularities in this rhythm currently, so
there is no immediate need to check vital
1. signs or laboratory results, or to notify the
Check vital signs. health care provider. Therefore, the nurse
2. would continue to monitor the client for any
Check laboratory test results. rhythm change.
3.
Notify the health care provider.
4.
Continue to monitor for any
rhythm change.
4. A client is wearing a contin- Check the client's status and lead place-
uous cardiac monitor, which ment.
begins to sound its alarm.
The nurse sees no electrocar- Sudden loss of electrocardiographic com-
diographic complexes on the plexes indicates ventricular asystole or
screen. Which is the priority possibly electrode displacement. Accurate
nursing action? assessment of the client and equipment
is necessary to determine the cause and
1. identify the appropriate intervention. The
Call a code. remaining options are secondary to client
2. assessment.
, SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
Call the health care provider.
3.
Check the client's status and
lead placement.
4.
Press the recorder button
on the electrocardiogram con-
sole.
5. The nurse is evaluating a Status of airway
client's response to cardiover-
sion. Which assessment would Nursing responsibilities after cardioversion
be the priority? include maintenance first of a patent air-
way, and then oxygen administration, as-
sessment of vital signs and level of con-
1. sciousness, and dysrhythmia detection.
Blood pressure
2.
Status of airway
3.
Oxygen flow rate
4.
Level of consciousness
6. The nurse is caring for a Activation status of the device, heart rate
client who has just had im- cutoff, and number of shocks it is pro-
plantation of an automatic grammed to deliver
internal cardioverter-defibrilla-
tor. The nurse should assess The nurse who is caring for the client af-
which item based on priority? ter insertion of an automatic internal car-
dioverter-defibrillator needs to assess de-
vice settings, similar to after insertion of
1. a permanent pacemaker. Specifically, the
Anxiety level of the client and nurse needs to know whether the device
family is activated, the heart rate cutoff above
2. which it will fire, and the number of shocks
Presence of a MedicAlert card it is programmed to deliver. The remaining
for the client to carry options are also nursing interventions but
3. are not the priority.
, SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
Knowledge of restrictions on
postdischarge physical activi-
ty
4.
Activation status of the device,
heart rate cutoff, and number
of shocks it is programmed to
deliver
7. A client's electrocardiogram Sinus tachycardia
strip shows atrial and ventric-
ular rates of 110 beats/minute. Sinus tachycardia has the characteristics
The PR interval is 0.14 sec- of normal sinus rhythm, including a regular
onds, the QRS complex mea- PP interval and normal-width PR and QRS
sures 0.08 seconds, and the PP intervals; however, the rate is the differenti-
and RR intervals are regular. ating factor. In sinus tachycardia, the atrial
How should the nurse correct- and ventricular rates are greater than 100
ly interpret this rhythm? beats/minute.
1.
Sinus tachycardia
2.
Sinus bradycardia
3.
Sinus dysrhythmia
4.
Normal sinus rhythm
8. The nurse is assessing the The neurovascular status is normal be-
neurovascular status of a cause of increased blood flow through the
client who returned to the sur- leg.
gical nursing unit 4 hours ago
after undergoing aortoiliac by- An expected outcome of aortoiliac bypass
pass graft. The affected leg graft surgery is warmth, redness, and ede-
is warm, and the nurse notes ma in the surgical extremity because of in-
redness and edema. The ped- creased blood flow. The remaining options
al pulse is palpable and un- are incorrect interpretations.
changed from admission. How
VERIFIED ANSWERS
1. A client admitted to the hospi- Metformin
tal with chest pain and a his-
tory of type 2 diabetes mel- Metformin needs to be withheld 24 hours
litus is scheduled for cardiac before and for 48 hours after cardiac
catheterization. Which medica- catheterization because of the injection of
tion would need to be withheld contrast medium during the procedure. If
for 24 hours before the proce- the contrast medium affects kidney func-
dure and for 48 hours after the tion, with metformin in the system the client
procedure? would be at increased risk for lactic acido-
sis. The medications in the remaining op-
tions do not need to be withheld 24 hours
1. before and 48 hours after cardiac catheter-
Glipizide ization.
2.
Metformin
3.
Repaglinide
4.
Regular insulin
2. A client who had cardiac Acute kidney injury
surgery 24 hours ago has had
a urine output averaging 20 The client who undergoes cardiac surgery
mL/hour for 2 hours. The client is at risk for renal injury from poor per-
received a single bolus of 500 fusion, hemolysis, low cardiac output, or
mL of intravenous fluid. Urine vasopressor medication therapy. Renal in-
output for the subsequent hour jury is signaled by decreased urine out-
was 25 mL. Daily laboratory re- put and increased blood urea nitrogen
sults indicate that the blood (BUN) and creatinine levels. Normal ref-
urea nitrogen level is 45 mg/dL erence levels are BUN, 10-20 mg/dL
(16 mmol/L) and the serum (3.6-7.1 mmol/L), and creatinine, male,
creatinine level is 2.2 mg/dL 0.6-1.2 mg/dL (53-106 mcmol/L) and fe-
(194 mcmol/L). On the basis male 0.5-1.1 mg/dL (44-97 mcmol/L). The
of these findings, the nurse client may need medications to increase
would anticipate that the client renal perfusion and possibly could need
is at risk for which problem? peritoneal dialysis or hemodialysis. No
data in the question indicate the presence
1. of hypovolemia, glomerulonephritis, or uri-
Hypovolemia nary tract infection.
, SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
2.
Acute kidney injury
3.
Glomerulonephritis
4.
Urinary tract infection
3. The nurse is reviewing an elec- Continue to monitor for any rhythm
trocardiogram rhythm strip. change.
The P waves and QRS com-
plexes are regular. The PR in- Normal sinus rhythm is defined as a reg-
terval is 0.16 seconds, and ular rhythm, with an overall rate of 60
QRS complexes measure 0.06 to 100 beats/minute. The PR and QRS
seconds. The overall heart rate measurements are normal, measuring be-
is 64 beats/minute. Which ac- tween 0.12 and 0.20 seconds and 0.04
tion should the nurse take? and 0.10 seconds, respectively. There are
no irregularities in this rhythm currently, so
there is no immediate need to check vital
1. signs or laboratory results, or to notify the
Check vital signs. health care provider. Therefore, the nurse
2. would continue to monitor the client for any
Check laboratory test results. rhythm change.
3.
Notify the health care provider.
4.
Continue to monitor for any
rhythm change.
4. A client is wearing a contin- Check the client's status and lead place-
uous cardiac monitor, which ment.
begins to sound its alarm.
The nurse sees no electrocar- Sudden loss of electrocardiographic com-
diographic complexes on the plexes indicates ventricular asystole or
screen. Which is the priority possibly electrode displacement. Accurate
nursing action? assessment of the client and equipment
is necessary to determine the cause and
1. identify the appropriate intervention. The
Call a code. remaining options are secondary to client
2. assessment.
, SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
Call the health care provider.
3.
Check the client's status and
lead placement.
4.
Press the recorder button
on the electrocardiogram con-
sole.
5. The nurse is evaluating a Status of airway
client's response to cardiover-
sion. Which assessment would Nursing responsibilities after cardioversion
be the priority? include maintenance first of a patent air-
way, and then oxygen administration, as-
sessment of vital signs and level of con-
1. sciousness, and dysrhythmia detection.
Blood pressure
2.
Status of airway
3.
Oxygen flow rate
4.
Level of consciousness
6. The nurse is caring for a Activation status of the device, heart rate
client who has just had im- cutoff, and number of shocks it is pro-
plantation of an automatic grammed to deliver
internal cardioverter-defibrilla-
tor. The nurse should assess The nurse who is caring for the client af-
which item based on priority? ter insertion of an automatic internal car-
dioverter-defibrillator needs to assess de-
vice settings, similar to after insertion of
1. a permanent pacemaker. Specifically, the
Anxiety level of the client and nurse needs to know whether the device
family is activated, the heart rate cutoff above
2. which it will fire, and the number of shocks
Presence of a MedicAlert card it is programmed to deliver. The remaining
for the client to carry options are also nursing interventions but
3. are not the priority.
, SAUNDERS NCLEX CARDIOVASCULAR TEST QUESTIONS WITH 100%
VERIFIED ANSWERS
Knowledge of restrictions on
postdischarge physical activi-
ty
4.
Activation status of the device,
heart rate cutoff, and number
of shocks it is programmed to
deliver
7. A client's electrocardiogram Sinus tachycardia
strip shows atrial and ventric-
ular rates of 110 beats/minute. Sinus tachycardia has the characteristics
The PR interval is 0.14 sec- of normal sinus rhythm, including a regular
onds, the QRS complex mea- PP interval and normal-width PR and QRS
sures 0.08 seconds, and the PP intervals; however, the rate is the differenti-
and RR intervals are regular. ating factor. In sinus tachycardia, the atrial
How should the nurse correct- and ventricular rates are greater than 100
ly interpret this rhythm? beats/minute.
1.
Sinus tachycardia
2.
Sinus bradycardia
3.
Sinus dysrhythmia
4.
Normal sinus rhythm
8. The nurse is assessing the The neurovascular status is normal be-
neurovascular status of a cause of increased blood flow through the
client who returned to the sur- leg.
gical nursing unit 4 hours ago
after undergoing aortoiliac by- An expected outcome of aortoiliac bypass
pass graft. The affected leg graft surgery is warmth, redness, and ede-
is warm, and the nurse notes ma in the surgical extremity because of in-
redness and edema. The ped- creased blood flow. The remaining options
al pulse is palpable and un- are incorrect interpretations.
changed from admission. How
