CARDIAC NCLEX TEST QUESTIONS AND
CORRECT ANSWERS
B
A. INCORRECT: Turning, coughing, and deep breathing should be performed every 2 hr to
promote oxygenation and circulation.
B. CORRECT: Providing adequate analgesia and returning in 15 min will reduce pain and
improve coughing effectiveness.
C. INCORRECT: This is not an adequate inspired air volume to promote effective oxygenation.
D. INCORRECT: This intervention is non-therapeutic communication.
A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting
(CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, and then refuses to
cough because he is tired and it hurts too much. Which of the following is an appropriate
nursing intervention?
A. Allow the client to rest, and return in 1 hr.
B. Administer IV bolus analgesic, and return in 15 min.
C. Document the 200 mL as an appropriate inspired volume.
D. Tell the client that he must try to cough if he does not want to get pneumonia.
B
A. INCORRECT: A trace of bloody drainage on the dressing is an expected finding and does not
require immediate concern.
B. CORRECT: Capillary refill greater than 2 to 4 seconds is outside the expected reference
range and should be reported to the provider.
C. CORRECT: Mottled appearance of the affected extremity is an unexpected finding and
should be reported to the provider.
D. INCORRECT: Pain that is decreased following IV bolus analgesia is an expected finding and
does not require immediate concern.
, E. INCORRECT: Pulse of 2+ in the affected extremity is an expected finding and does not
require immediate concern.
A nurse is caring for a client following peripheral bypass graft surgery of the left lower
extremity. Which of the following client findings pose an immediate concern? (Select all that
apply.)
A. Trace of bloody drainage on dressing
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
D. Throbbing pain of affected limb that is decreased following IV bolus analgesic
E. Pulse of 2+ in the affected limb
D
A. INCORRECT: Reddening (rubor) of a leg affected by peripheral artery disease occurs when it
is placed in a dependent position.
B. INCORRECT: Pulses are decreased or absent in the feet in cases of peripheral artery
disease.
C. INCORRECT: Toenails are thickened in cases of peripheral artery disease.
D. CORRECT: A client who has peripheral artery disease may report that numbness or burning
pain in the extremity ceases with rest (intermittent claudication).
A nurse is completing the admission assessment of a client who will undergo peripheral bypass
graft surgery on the left leg. Which of the following is an expected finding?
A. Rubor of the affected leg when elevated
B. 3+ dorsal pedal pulse in left foot
C. Thin, peeling toenails of left foot
D. Report of intermittent claudication in the affected leg
S3: Remains constant through respiration, possible sign of ventricular failure
When auscultating heart, extra heart sound at apex after S2 is heard throughout respiratory
cycle:
CORRECT ANSWERS
B
A. INCORRECT: Turning, coughing, and deep breathing should be performed every 2 hr to
promote oxygenation and circulation.
B. CORRECT: Providing adequate analgesia and returning in 15 min will reduce pain and
improve coughing effectiveness.
C. INCORRECT: This is not an adequate inspired air volume to promote effective oxygenation.
D. INCORRECT: This intervention is non-therapeutic communication.
A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting
(CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, and then refuses to
cough because he is tired and it hurts too much. Which of the following is an appropriate
nursing intervention?
A. Allow the client to rest, and return in 1 hr.
B. Administer IV bolus analgesic, and return in 15 min.
C. Document the 200 mL as an appropriate inspired volume.
D. Tell the client that he must try to cough if he does not want to get pneumonia.
B
A. INCORRECT: A trace of bloody drainage on the dressing is an expected finding and does not
require immediate concern.
B. CORRECT: Capillary refill greater than 2 to 4 seconds is outside the expected reference
range and should be reported to the provider.
C. CORRECT: Mottled appearance of the affected extremity is an unexpected finding and
should be reported to the provider.
D. INCORRECT: Pain that is decreased following IV bolus analgesia is an expected finding and
does not require immediate concern.
, E. INCORRECT: Pulse of 2+ in the affected extremity is an expected finding and does not
require immediate concern.
A nurse is caring for a client following peripheral bypass graft surgery of the left lower
extremity. Which of the following client findings pose an immediate concern? (Select all that
apply.)
A. Trace of bloody drainage on dressing
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
D. Throbbing pain of affected limb that is decreased following IV bolus analgesic
E. Pulse of 2+ in the affected limb
D
A. INCORRECT: Reddening (rubor) of a leg affected by peripheral artery disease occurs when it
is placed in a dependent position.
B. INCORRECT: Pulses are decreased or absent in the feet in cases of peripheral artery
disease.
C. INCORRECT: Toenails are thickened in cases of peripheral artery disease.
D. CORRECT: A client who has peripheral artery disease may report that numbness or burning
pain in the extremity ceases with rest (intermittent claudication).
A nurse is completing the admission assessment of a client who will undergo peripheral bypass
graft surgery on the left leg. Which of the following is an expected finding?
A. Rubor of the affected leg when elevated
B. 3+ dorsal pedal pulse in left foot
C. Thin, peeling toenails of left foot
D. Report of intermittent claudication in the affected leg
S3: Remains constant through respiration, possible sign of ventricular failure
When auscultating heart, extra heart sound at apex after S2 is heard throughout respiratory
cycle:
