Cardiac unit: nclex questions(2023)
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a
prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates
which action?
A. adding a dose of heparin sodium
B. holding the next dose of warfarin
C. increasing the next dose of warfarin
D. administering the next dose of warfarin - B. holding the next dose of warfarin
Rationale: The normal PT time it 11 to 12.5 seconds. Aterm-0 therapeutic PT level is 1.5 to 2 times higher
than the normal level so the dose will need to be held.
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis.
The clients activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates which
action is needed?
A. discontinuing the heparin infusion
B. increasing the rate of the heparin infusion
C. decreasing the rate of the heparin infusion
D. Leaving the rate of the heparin infusion as is - D. leaving the rate of the heparin infusion as is
Rationale: the normal aPTT varies between 30 and 40. The therapeutic dose of heparin for treatment of
deep vein thrombosis is to keep the aPTT less than 45 seconds or greater than 100 seconds. Thus the
clients aPTT is within therapeutic range not needing to be changed.
The nurse administered intravenous bumetanide to a client being treated for heart failure. Which
outcome indicates that the medication had achieved the expected affect?
A. cough becomes productive of frothy pink sputum
B. Urine output increases from 10 mL hourly
C. the serum potassium level changes from 3.8 to 3.1 mEq/L
,D. b-type natriuretic peptide (BNP) factor increases form 200 to 262 ng/mL - B. urine output increases
from 10 mL hourly
rationale: bumetanide is a diuretic with an expected outcome of increased urine output. Potassium loss
is a side effect rather than an expected affect of the diuretic.
Intravenous heparin therapy is prescribed for a client with atrial fibrillation. While implementing this
prescription, the nurse ensures that which medication is available in the nursing unit?
A. vitamin K
B. protamine sulfate
C. potassium chloride
D. aminocaproic acid - B. protamine sulfate
The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who is
taking nitroglycerin for chest pain at home. During the assessment the client complains of chest pain.
The nurse should immediately ask the client which questions?
A. "Where is the pain located?"
B. "Are you having nay nausea?"
C. "Are you allergic to any medications?"
D. " DO you have your nitroglycerin with you?" - A. "where is the pain located?"
rationale: If a client complains of chest pain the initial assessment question is to ask the client about the
pain intensity, location, duration, & quality
A client in Sinus bradycardia, with a heart rate of 45 beats per minute and a BP of 82/60 mmHg, reports
dizziness. Which intervention should the nurse anticipate will be prescribed?
A. administer digoxin
B. defibrillate the client
C. continue to monitor the client
D. prepare for transcutaneous pacing - D. prepare for transcutaneous pacing
rationale: Sinus bradycardia is noted when HR in less than 60 bpm. Rhythm becomes a concern when
the client becomes symptomatic such as dizzy & light headed. transcutaneous pacing provides
temporary measure to increase HR and perfusion in client.
,The nurse is watching the cardiac monitor and notices that a clients rhythm suddenly changes. There
are no P waves, the QRS interval are wide, and the ventricular rate is regular but more than 140 beats
per minute. The nurse determines that the client is experiencing which dysrhythmias?
A. sinus tachycardia
B. ventricular fibrillation
C. ventricular tachycardia
D. premature ventricular contractions - C. ventricular tachycardia
rationale: ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes, &
typically a rate between 140 and 180 pulse per minute
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be
most concerned about with this dysrhythmias?
A. it can develop into ventricular fibrillation at any time
B. it is almost impossible to convert to a normal rhythm
C. is it uncomfortable for the client, giving a sense of impending doom
D. it produces a high cardiac output with cerebral and myocardial ischemia - A. it can develop into
ventricular fibrillation at any time
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P
waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse interpret
the client's heart rhythm?
A. atrial fibrillation
B. sinus tachycardia
C. ventricular fibrillation
D. ventricular tachycardia - A. atrial fibrillation
rationale: atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS
complex. The atria quiver, which can lead to thrombus formation.
The nurse is evaluating a client's response to a cardioversion. Which assessment would be the priority?
A. blood pressure
B. airway patency
C. oxygen flow rate
, D. level of consciousness - B. airway patency
The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental
concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart
responsible for initiating electrical impulses is which site?
A. bundle of HIS
B. purkinje fibers
C. Sinoatrial node
D. atrioventricular node - C. Sinoatrial (SA) node
Potassium chloride is prescribed for a client with heart failure experiencing hypokalemia. Which actions
should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
A. obtain an IV infusion pump
B. monitor urine output during administration
C. prepare the medication for bolus administration
D. monitor IV site for signs of infiltration or phlebitis
E. ensure the medication is diluted in the appropriate volume of fluid
F. ensure that the bag is labeled so that it reads the volume of potassium in the solution - A. obtain an
IV infusion pump
B. monitor urine output during administration
D. monitor IV site for signs of infiltration or phlebitis
E. ensure the medication is diluted in the appropriate volume of fluid
F. ensure that the bag is labeled so that it reads the volume of potassium in the solution
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, & lung crackles. The nurse immediately asks another nurse to contact the
healthcare provider and prepares to implement which priority interventions? Select all that apply.
A. administer oxygen
B. inserting a Foley catheter
C. administer furosemide
D. administering morphine sulfate intravenously
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a
prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates
which action?
A. adding a dose of heparin sodium
B. holding the next dose of warfarin
C. increasing the next dose of warfarin
D. administering the next dose of warfarin - B. holding the next dose of warfarin
Rationale: The normal PT time it 11 to 12.5 seconds. Aterm-0 therapeutic PT level is 1.5 to 2 times higher
than the normal level so the dose will need to be held.
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis.
The clients activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates which
action is needed?
A. discontinuing the heparin infusion
B. increasing the rate of the heparin infusion
C. decreasing the rate of the heparin infusion
D. Leaving the rate of the heparin infusion as is - D. leaving the rate of the heparin infusion as is
Rationale: the normal aPTT varies between 30 and 40. The therapeutic dose of heparin for treatment of
deep vein thrombosis is to keep the aPTT less than 45 seconds or greater than 100 seconds. Thus the
clients aPTT is within therapeutic range not needing to be changed.
The nurse administered intravenous bumetanide to a client being treated for heart failure. Which
outcome indicates that the medication had achieved the expected affect?
A. cough becomes productive of frothy pink sputum
B. Urine output increases from 10 mL hourly
C. the serum potassium level changes from 3.8 to 3.1 mEq/L
,D. b-type natriuretic peptide (BNP) factor increases form 200 to 262 ng/mL - B. urine output increases
from 10 mL hourly
rationale: bumetanide is a diuretic with an expected outcome of increased urine output. Potassium loss
is a side effect rather than an expected affect of the diuretic.
Intravenous heparin therapy is prescribed for a client with atrial fibrillation. While implementing this
prescription, the nurse ensures that which medication is available in the nursing unit?
A. vitamin K
B. protamine sulfate
C. potassium chloride
D. aminocaproic acid - B. protamine sulfate
The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who is
taking nitroglycerin for chest pain at home. During the assessment the client complains of chest pain.
The nurse should immediately ask the client which questions?
A. "Where is the pain located?"
B. "Are you having nay nausea?"
C. "Are you allergic to any medications?"
D. " DO you have your nitroglycerin with you?" - A. "where is the pain located?"
rationale: If a client complains of chest pain the initial assessment question is to ask the client about the
pain intensity, location, duration, & quality
A client in Sinus bradycardia, with a heart rate of 45 beats per minute and a BP of 82/60 mmHg, reports
dizziness. Which intervention should the nurse anticipate will be prescribed?
A. administer digoxin
B. defibrillate the client
C. continue to monitor the client
D. prepare for transcutaneous pacing - D. prepare for transcutaneous pacing
rationale: Sinus bradycardia is noted when HR in less than 60 bpm. Rhythm becomes a concern when
the client becomes symptomatic such as dizzy & light headed. transcutaneous pacing provides
temporary measure to increase HR and perfusion in client.
,The nurse is watching the cardiac monitor and notices that a clients rhythm suddenly changes. There
are no P waves, the QRS interval are wide, and the ventricular rate is regular but more than 140 beats
per minute. The nurse determines that the client is experiencing which dysrhythmias?
A. sinus tachycardia
B. ventricular fibrillation
C. ventricular tachycardia
D. premature ventricular contractions - C. ventricular tachycardia
rationale: ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes, &
typically a rate between 140 and 180 pulse per minute
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be
most concerned about with this dysrhythmias?
A. it can develop into ventricular fibrillation at any time
B. it is almost impossible to convert to a normal rhythm
C. is it uncomfortable for the client, giving a sense of impending doom
D. it produces a high cardiac output with cerebral and myocardial ischemia - A. it can develop into
ventricular fibrillation at any time
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P
waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse interpret
the client's heart rhythm?
A. atrial fibrillation
B. sinus tachycardia
C. ventricular fibrillation
D. ventricular tachycardia - A. atrial fibrillation
rationale: atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS
complex. The atria quiver, which can lead to thrombus formation.
The nurse is evaluating a client's response to a cardioversion. Which assessment would be the priority?
A. blood pressure
B. airway patency
C. oxygen flow rate
, D. level of consciousness - B. airway patency
The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental
concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart
responsible for initiating electrical impulses is which site?
A. bundle of HIS
B. purkinje fibers
C. Sinoatrial node
D. atrioventricular node - C. Sinoatrial (SA) node
Potassium chloride is prescribed for a client with heart failure experiencing hypokalemia. Which actions
should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
A. obtain an IV infusion pump
B. monitor urine output during administration
C. prepare the medication for bolus administration
D. monitor IV site for signs of infiltration or phlebitis
E. ensure the medication is diluted in the appropriate volume of fluid
F. ensure that the bag is labeled so that it reads the volume of potassium in the solution - A. obtain an
IV infusion pump
B. monitor urine output during administration
D. monitor IV site for signs of infiltration or phlebitis
E. ensure the medication is diluted in the appropriate volume of fluid
F. ensure that the bag is labeled so that it reads the volume of potassium in the solution
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, & lung crackles. The nurse immediately asks another nurse to contact the
healthcare provider and prepares to implement which priority interventions? Select all that apply.
A. administer oxygen
B. inserting a Foley catheter
C. administer furosemide
D. administering morphine sulfate intravenously
