Page | 1
CARDIAC NCLEX EXAM /NCLEX
CARDIAC EXAM ACTUAL EXAM
Questions and Answers (Expert Solutions)
Q: 1) A client is scheduled for a cardiac catherization using a radiopaque dye. Which of
the following assessments is most critical before the procedure?
1.Intake and output
2.Baseline peripheral pulse rates
3.Height and weight
4.Allergy to iodine or shellfish, 🗹🗹: 4. Allergy to iodine or shellfish
This procedure requires an informed consent because it involves injection of a
radiopaque dye into the blood vessel. The risk of allergic reaction and possible
anaphylaxis is serious and must be assessed before the procedure.
Q: 2) A client with no history of cardiovascular disease comes into the ambulatory clinic
with flulike symptoms. The client suddenly complains of chest pain. Which of the
following questions would best help a nurse to discriminate pain caused by a non-cardiac
problem?
1."Have you ever had this pain before?"
2."Can you describe the pain to me?"
3."Does the pain get worse when you breathe in?"
4."Can you rate the pain on a scale of 1-10, with 10 being the worst?", 🗹🗹: 3."Does
the pain get worse when you breathe in?"
Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2,
and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary
origin usually worsens on inspiration.
Q: 3) A client with myocardial infarction has been transferred from a coronary care unit
to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow
for which of the following client activities?
1.Strict bed rest for 24 hours after transfer
2.Bathroom privileges and self-care activities
, Page | 2
3.Unsupervised hallway ambulation with distances under 200 feet
4.Ad lib activities because the client is monitored., 🗹🗹: 2. Bathroom privileges and
self-care activities
On transfer from the CCU, the client is allowed self-care activities and bathroom
privileges. Supervised ambulation for brief distances are encouraged, with distances
gradually increased (50, 100, 200 feet).
Q: A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial
infarction who was admitted 2 days ago. The nurse would plan to do which of the
following next?
1.Review the intake and output records for the last 2 days
2.Change the time of diuretic administration from morning to evening
3.Request a sodium restriction of 1 g/day from the physician.
4.Order daily weights starting the following morning., 🗹🗹: 1.Review the intake and
output records for the last 2 days
Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by
intake greater than output and by a sudden increase in weight. Diuretics should be
given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are
reserved for clients with severe symptoms.
Q: A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A
nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is
to:
1.Check the client status and lead placement
2.Press the recorder button on the electrocardiogram console.
3.Call the physician
4.Call a code blue, 🗹🗹: 1. Check the client status and lead placement
Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible
electrode displacement. Accurate assessment of the client and equipment is necessary
to determine the cause and identify the appropriate intervention.
Q: 6) A nurse is assessing the blood pressure of a client diagnosed with primary
hypertension. The nurse ensures accurate measurement by avoiding which of the
following?
1.Seating the client with arm bared, supported, and at heart level.
, Page | 3
2.Measuring the blood pressure after the client has been seated quietly for 5 minutes.
3.Using a cuff with a rubber bladder that encircles at least 80% of the limb.
4.Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.,
🗹🗹: 4.Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion
BP should be taken with the client seated with the arm bared, positioned with support
and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not
speak during the recording. The client should not have smoked tobacco or taken in
caffeine in the 30 minutes preceding the measurement. The client should rest quietly for
5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of
the limb being measured. Gauges other than a mercury sphygmomanometer should be
calibrated every 6 months to ensure accuracy
Q: 7) IV heparin therapy is ordered for a client. While implementing this order, a nurse
ensures that which of the following medications is available on the nursing unit?
1.Vitamin K
2.Aminocaporic acid
3.Potassium chloride
4.Protamine sulfate, 🗹🗹: 4. Protamine sulfate
The antidote to heparin is protamine sulfate and should be readily available for use if
excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin.
Q: 8) A client is at risk for pulmonary embolism and is on anticoagulant therapy with
warfarin (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11
seconds. The nurse assesses that this result is:
1.The same as the client's own baseline level
2.Lower than the needed therapeutic level
3.Within the therapeutic range
4.Higher than the therapeutic range, 🗹🗹: 3. Within the therapeutic range (11 x
1.5=16.5)
The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at
risk for thrombus. Based on the client's control value, the therapeutic range for this
individual would be 16.5 to 22 seconds. Therefore the result is within therapeutic range
Q: 9) A client who has been receiving heparin therapy also is started on warfarin. The
client asks a nurse why both medications are being administered. In formulating a
response, the nurse incorporates the understanding that warfarin:
CARDIAC NCLEX EXAM /NCLEX
CARDIAC EXAM ACTUAL EXAM
Questions and Answers (Expert Solutions)
Q: 1) A client is scheduled for a cardiac catherization using a radiopaque dye. Which of
the following assessments is most critical before the procedure?
1.Intake and output
2.Baseline peripheral pulse rates
3.Height and weight
4.Allergy to iodine or shellfish, 🗹🗹: 4. Allergy to iodine or shellfish
This procedure requires an informed consent because it involves injection of a
radiopaque dye into the blood vessel. The risk of allergic reaction and possible
anaphylaxis is serious and must be assessed before the procedure.
Q: 2) A client with no history of cardiovascular disease comes into the ambulatory clinic
with flulike symptoms. The client suddenly complains of chest pain. Which of the
following questions would best help a nurse to discriminate pain caused by a non-cardiac
problem?
1."Have you ever had this pain before?"
2."Can you describe the pain to me?"
3."Does the pain get worse when you breathe in?"
4."Can you rate the pain on a scale of 1-10, with 10 being the worst?", 🗹🗹: 3."Does
the pain get worse when you breathe in?"
Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2,
and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary
origin usually worsens on inspiration.
Q: 3) A client with myocardial infarction has been transferred from a coronary care unit
to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow
for which of the following client activities?
1.Strict bed rest for 24 hours after transfer
2.Bathroom privileges and self-care activities
, Page | 2
3.Unsupervised hallway ambulation with distances under 200 feet
4.Ad lib activities because the client is monitored., 🗹🗹: 2. Bathroom privileges and
self-care activities
On transfer from the CCU, the client is allowed self-care activities and bathroom
privileges. Supervised ambulation for brief distances are encouraged, with distances
gradually increased (50, 100, 200 feet).
Q: A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial
infarction who was admitted 2 days ago. The nurse would plan to do which of the
following next?
1.Review the intake and output records for the last 2 days
2.Change the time of diuretic administration from morning to evening
3.Request a sodium restriction of 1 g/day from the physician.
4.Order daily weights starting the following morning., 🗹🗹: 1.Review the intake and
output records for the last 2 days
Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by
intake greater than output and by a sudden increase in weight. Diuretics should be
given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are
reserved for clients with severe symptoms.
Q: A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A
nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is
to:
1.Check the client status and lead placement
2.Press the recorder button on the electrocardiogram console.
3.Call the physician
4.Call a code blue, 🗹🗹: 1. Check the client status and lead placement
Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible
electrode displacement. Accurate assessment of the client and equipment is necessary
to determine the cause and identify the appropriate intervention.
Q: 6) A nurse is assessing the blood pressure of a client diagnosed with primary
hypertension. The nurse ensures accurate measurement by avoiding which of the
following?
1.Seating the client with arm bared, supported, and at heart level.
, Page | 3
2.Measuring the blood pressure after the client has been seated quietly for 5 minutes.
3.Using a cuff with a rubber bladder that encircles at least 80% of the limb.
4.Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.,
🗹🗹: 4.Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion
BP should be taken with the client seated with the arm bared, positioned with support
and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not
speak during the recording. The client should not have smoked tobacco or taken in
caffeine in the 30 minutes preceding the measurement. The client should rest quietly for
5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of
the limb being measured. Gauges other than a mercury sphygmomanometer should be
calibrated every 6 months to ensure accuracy
Q: 7) IV heparin therapy is ordered for a client. While implementing this order, a nurse
ensures that which of the following medications is available on the nursing unit?
1.Vitamin K
2.Aminocaporic acid
3.Potassium chloride
4.Protamine sulfate, 🗹🗹: 4. Protamine sulfate
The antidote to heparin is protamine sulfate and should be readily available for use if
excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin.
Q: 8) A client is at risk for pulmonary embolism and is on anticoagulant therapy with
warfarin (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11
seconds. The nurse assesses that this result is:
1.The same as the client's own baseline level
2.Lower than the needed therapeutic level
3.Within the therapeutic range
4.Higher than the therapeutic range, 🗹🗹: 3. Within the therapeutic range (11 x
1.5=16.5)
The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at
risk for thrombus. Based on the client's control value, the therapeutic range for this
individual would be 16.5 to 22 seconds. Therefore the result is within therapeutic range
Q: 9) A client who has been receiving heparin therapy also is started on warfarin. The
client asks a nurse why both medications are being administered. In formulating a
response, the nurse incorporates the understanding that warfarin:
