CARDIOVASCULAR NCLEX Actual
Exam-A Grade | 147 Questions |
Correct Answers and Rationales
A client with iron deficiency anemia complains of feeling fatigued almost all of the time.
The nurse should respond with which statement?
1."The work of breathing is increased when the client is anemic." 2."Blood flows more slowly
when the hemoglobin or hematocrit is low." 3."The body has to work harder to fight
infection in the presence of anemia." 4."Adequate amounts of hemoglobin are needed to
carry oxygen for tissue metabolism."
4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."
Rationale:Oxygen is required to meet the metabolic needs of the body. With decreased
hemoglobin, such as in iron deficiency anemia, the oxygen-carrying capacity of the blood is
less than normal. The client feels the effects of this change as fatigue. The statements in the
remaining options are incorrect.
The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels.
Which statement by one of the new RNs indicates that teaching has been effective?
,1."Calcium has no effect on the risk for stroke." 2."Low calcium levels can lead to cardiac
arrest." 3."Low calcium levels cause high blood pressure." 4."Calcium has no effect on
urinary stone formation."
2."Low calcium levels can lead to cardiac arrest."
Rationale:The normal calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A low calcium
level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately
cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell
membranes into cardiac cells during depolarization and move back during repolarization.
Depolarization is responsible for cardiac contraction. Options 1 and 3 are unrelated to calcium
levels. Elevated calcium levels can lead to urinary stone formation. The nurse would take
action and contact the health care provider when a calcium level is abnormal.
The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving
intravenous doses of furosemide. The client is attached to cardiac telemetry, and the nurse
is monitoring the client's cardiac status. The nurse notes that the client's cardiac rhythm has
changed to this pattern. The nurse determines that the most likely cause of this cardiac
rhythm in the client is which problem? Refer to figure.
1.Pacemaker dysfunction 2.The presence of hypokalemia 3.The effectiveness of the
furosemide 4.An impending myocardial infarction (MI)
2.The presence of hypokalemia
Rationale:This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular
complexes (PVCs). PVCs may be insignificant, or they may occur with myocardial ischemia or
MI; heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or
alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, a diuretic
that causes the excretion of potassium. The most likely cause of the PVCs in this client is
hypokalemia. Option 3 is an incorrect interpretation. The question presents no data indicating
that this client has a pacemaker or has signs or symptoms of an impending MI.
,The nurse is teaching a client with cardiomyopathy about home care safety measures. The
nurse should address with the client which most important measure to ensure client safety?
1.Assessing pain 2.Administering vasodilators 3.Avoiding over-the-counter (OTC)
medications 4.Moving slowly from a sitting to a standing position
4.Moving slowly from a sitting to a standing position
Rationale:Orthostatic changes can occur in the client with cardiomyopathy as a result of venous
return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally
are not prescribed for the client with cardiomyopathy. Although important, pain assessment
and avoiding OTC medications are not directly related to the issue of safety.
The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new
RN indicates an understanding of an early indication of fluid volume deficit due to blood loss?
1."Pulse rate will increase." 2."Blood pressure will decrease." 3."Edema will be present in the
legs." 4."Crackles in the lungs will be present."
1."Pulse rate will increase."
Rationale:The cardiac output is determined by the volume of the circulating blood, the
pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume
are compensated for by an increase in the pulse rate. Although the blood pressure will
decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in
fluid overload.
A client with myocardial infarction is experiencing new, multiform premature
ventricular contractions and short runs of ventricular tachycardia. The nurse plans to
have which medication available for immediate use to treat the ventricular tachycardia?
1.Digoxin 2.Verapamil 3.Acebutolol 4.Amiodarone
4.Amiodarone
Rationale:Amiodarone is an antidysrhythmic that may be used to treat ventricular
dysrhythmias. Digoxin is a cardiac glycoside; verapamil is a calcium channel-blocking agent;
, acebutolol is a beta-adrenergic blocking agent. Digoxin can be used to treat supraventricular
dysrhythmias but is inactive against ventricular dysrhythmias. Verapamil is used to slow the
ventricular rate for a client with atrial fibrillation or atrial flutter, or to terminate
supraventricular tachycardia. Acebutolol is a beta blocker used to treat dysrhythmias.
A client has received antidysrhythmic therapy for the treatment of premature
ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if
which finding is noted with regard to the PVCs?
1.They occur in pairs. 2.They appear to be multifocal. 3.They fall on the second half of the
T wave. 4.They decrease to a frequency of less than 6 per minute.
4.They decrease to a frequency of less than 6 per minute.
Rationale:PVCs are considered dangerous when they are frequent (more than 6 per
minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each
of these instances, the client's cardiac rhythm is likely to degenerate into ventricular
tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias.
After instruction on the application of antiembolism stockings, the nurse determines that
the client requires further teaching if which of these actions is performed?
1.The client puts on the stockings before getting out of bed. 2.The client bunches up the
stockings for easier application. 3.The client ensures that stockings are pulled up all the
way. 4.The client ensures that the rough seams of the stockings are on the outside.
2.The client bunches up the stockings for easier application.
Rationale:When applying antiembolism stockings, the client should not bunch up the stockings.
Instead, the client should place the hand inside the stocking and pull the heel out. The foot of
the stocking should then be placed over the client's foot and the rest of the stocking pulled up
the leg. This will help to prevent wrinkling and twisting of the stocking. The remaining options
demonstrate correct application of the stockings.
Exam-A Grade | 147 Questions |
Correct Answers and Rationales
A client with iron deficiency anemia complains of feeling fatigued almost all of the time.
The nurse should respond with which statement?
1."The work of breathing is increased when the client is anemic." 2."Blood flows more slowly
when the hemoglobin or hematocrit is low." 3."The body has to work harder to fight
infection in the presence of anemia." 4."Adequate amounts of hemoglobin are needed to
carry oxygen for tissue metabolism."
4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."
Rationale:Oxygen is required to meet the metabolic needs of the body. With decreased
hemoglobin, such as in iron deficiency anemia, the oxygen-carrying capacity of the blood is
less than normal. The client feels the effects of this change as fatigue. The statements in the
remaining options are incorrect.
The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels.
Which statement by one of the new RNs indicates that teaching has been effective?
,1."Calcium has no effect on the risk for stroke." 2."Low calcium levels can lead to cardiac
arrest." 3."Low calcium levels cause high blood pressure." 4."Calcium has no effect on
urinary stone formation."
2."Low calcium levels can lead to cardiac arrest."
Rationale:The normal calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A low calcium
level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately
cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell
membranes into cardiac cells during depolarization and move back during repolarization.
Depolarization is responsible for cardiac contraction. Options 1 and 3 are unrelated to calcium
levels. Elevated calcium levels can lead to urinary stone formation. The nurse would take
action and contact the health care provider when a calcium level is abnormal.
The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving
intravenous doses of furosemide. The client is attached to cardiac telemetry, and the nurse
is monitoring the client's cardiac status. The nurse notes that the client's cardiac rhythm has
changed to this pattern. The nurse determines that the most likely cause of this cardiac
rhythm in the client is which problem? Refer to figure.
1.Pacemaker dysfunction 2.The presence of hypokalemia 3.The effectiveness of the
furosemide 4.An impending myocardial infarction (MI)
2.The presence of hypokalemia
Rationale:This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular
complexes (PVCs). PVCs may be insignificant, or they may occur with myocardial ischemia or
MI; heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or
alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, a diuretic
that causes the excretion of potassium. The most likely cause of the PVCs in this client is
hypokalemia. Option 3 is an incorrect interpretation. The question presents no data indicating
that this client has a pacemaker or has signs or symptoms of an impending MI.
,The nurse is teaching a client with cardiomyopathy about home care safety measures. The
nurse should address with the client which most important measure to ensure client safety?
1.Assessing pain 2.Administering vasodilators 3.Avoiding over-the-counter (OTC)
medications 4.Moving slowly from a sitting to a standing position
4.Moving slowly from a sitting to a standing position
Rationale:Orthostatic changes can occur in the client with cardiomyopathy as a result of venous
return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally
are not prescribed for the client with cardiomyopathy. Although important, pain assessment
and avoiding OTC medications are not directly related to the issue of safety.
The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new
RN indicates an understanding of an early indication of fluid volume deficit due to blood loss?
1."Pulse rate will increase." 2."Blood pressure will decrease." 3."Edema will be present in the
legs." 4."Crackles in the lungs will be present."
1."Pulse rate will increase."
Rationale:The cardiac output is determined by the volume of the circulating blood, the
pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume
are compensated for by an increase in the pulse rate. Although the blood pressure will
decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in
fluid overload.
A client with myocardial infarction is experiencing new, multiform premature
ventricular contractions and short runs of ventricular tachycardia. The nurse plans to
have which medication available for immediate use to treat the ventricular tachycardia?
1.Digoxin 2.Verapamil 3.Acebutolol 4.Amiodarone
4.Amiodarone
Rationale:Amiodarone is an antidysrhythmic that may be used to treat ventricular
dysrhythmias. Digoxin is a cardiac glycoside; verapamil is a calcium channel-blocking agent;
, acebutolol is a beta-adrenergic blocking agent. Digoxin can be used to treat supraventricular
dysrhythmias but is inactive against ventricular dysrhythmias. Verapamil is used to slow the
ventricular rate for a client with atrial fibrillation or atrial flutter, or to terminate
supraventricular tachycardia. Acebutolol is a beta blocker used to treat dysrhythmias.
A client has received antidysrhythmic therapy for the treatment of premature
ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if
which finding is noted with regard to the PVCs?
1.They occur in pairs. 2.They appear to be multifocal. 3.They fall on the second half of the
T wave. 4.They decrease to a frequency of less than 6 per minute.
4.They decrease to a frequency of less than 6 per minute.
Rationale:PVCs are considered dangerous when they are frequent (more than 6 per
minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each
of these instances, the client's cardiac rhythm is likely to degenerate into ventricular
tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias.
After instruction on the application of antiembolism stockings, the nurse determines that
the client requires further teaching if which of these actions is performed?
1.The client puts on the stockings before getting out of bed. 2.The client bunches up the
stockings for easier application. 3.The client ensures that stockings are pulled up all the
way. 4.The client ensures that the rough seams of the stockings are on the outside.
2.The client bunches up the stockings for easier application.
Rationale:When applying antiembolism stockings, the client should not bunch up the stockings.
Instead, the client should place the hand inside the stocking and pull the heel out. The foot of
the stocking should then be placed over the client's foot and the rest of the stocking pulled up
the leg. This will help to prevent wrinkling and twisting of the stocking. The remaining options
demonstrate correct application of the stockings.
