Cardiovascular NCLEX questions & Correct
Answers -100% Verified Rationales
1) A client is scheduled for a cardiac catherization using a radiopaque dye. Which of
the following assessments is most critical before the procedure?
Intake and output
Baseline peripheral pulse rates
Height and weight
Allergy to iodine or shellfish - ✔✔4.
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.
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?
,"Have you ever had this pain before?"
"Can you describe the pain to me?"
"Does the pain get worse when you breathe in?"
"Can you rate the pain on a scale of 1-10, with 10 being the worst?" - ✔✔3.
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?
Strict bed rest for 24 hours after transfer
Bathroom privileges and self-care activities
Unsupervised hallway ambulation with distances under 200 feet
Ad lib activities because the client is monitored. - ✔✔2.
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).
4) 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?
Review the intake and output records for the last 2 days
Change the time of diuretic administration from morning to evening
Request a sodium restriction of 1 g/day from the physician.
Order daily weights starting the following morning. - ✔✔1.
,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.
5) 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:
Check the client status and lead placement
Press the recorder button on the electrocardiogram console.
Call the physician
Call a code blue - ✔✔1.
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?
Seating the client with arm bared, supported, and at heart level.
Measuring the blood pressure after the client has been seated quietly for 5 minutes.
Using a cuff with a rubber bladder that encircles at least 80% of the limb.
Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. - ✔✔4.
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.
, 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?
Vitamin K
Aminocaporic acid
Potassium chloride
Protamine sulfate - ✔✔4.
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.
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:
The same as the client's own baseline level
Lower than the needed therapeutic level
Within the therapeutic range
Higher than the therapeutic range - ✔✔3.
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.
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:
Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this
to exert an anticoagulant effect.
Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this
medication to exert an anticoagulant effect.
Answers -100% Verified Rationales
1) A client is scheduled for a cardiac catherization using a radiopaque dye. Which of
the following assessments is most critical before the procedure?
Intake and output
Baseline peripheral pulse rates
Height and weight
Allergy to iodine or shellfish - ✔✔4.
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.
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?
,"Have you ever had this pain before?"
"Can you describe the pain to me?"
"Does the pain get worse when you breathe in?"
"Can you rate the pain on a scale of 1-10, with 10 being the worst?" - ✔✔3.
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?
Strict bed rest for 24 hours after transfer
Bathroom privileges and self-care activities
Unsupervised hallway ambulation with distances under 200 feet
Ad lib activities because the client is monitored. - ✔✔2.
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).
4) 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?
Review the intake and output records for the last 2 days
Change the time of diuretic administration from morning to evening
Request a sodium restriction of 1 g/day from the physician.
Order daily weights starting the following morning. - ✔✔1.
,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.
5) 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:
Check the client status and lead placement
Press the recorder button on the electrocardiogram console.
Call the physician
Call a code blue - ✔✔1.
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?
Seating the client with arm bared, supported, and at heart level.
Measuring the blood pressure after the client has been seated quietly for 5 minutes.
Using a cuff with a rubber bladder that encircles at least 80% of the limb.
Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. - ✔✔4.
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.
, 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?
Vitamin K
Aminocaporic acid
Potassium chloride
Protamine sulfate - ✔✔4.
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.
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:
The same as the client's own baseline level
Lower than the needed therapeutic level
Within the therapeutic range
Higher than the therapeutic range - ✔✔3.
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.
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:
Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this
to exert an anticoagulant effect.
Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this
medication to exert an anticoagulant effect.
