CARDIAC NCLEX EXAM SCRIPT
COMPREHENSIVE STUDY GUIDE
●● 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?"
Answer: 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.
●● 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
,3.Unsupervised hallway ambulation with distances under 200 feet
4.Ad lib activities because the client is monitored.
Answer: 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).
●● 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.
Answer: 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.
, ●● 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
Answer: 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.
●● 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.
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.
COMPREHENSIVE STUDY GUIDE
●● 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?"
Answer: 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.
●● 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
,3.Unsupervised hallway ambulation with distances under 200 feet
4.Ad lib activities because the client is monitored.
Answer: 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).
●● 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.
Answer: 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.
, ●● 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
Answer: 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.
●● 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.
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.
