NCLEX Cardiac Critical Care Exam with precise
detailed answers
The nurse is caring for an adult pt who is admitted with chest pain that began four hours
ago. Which test will be most specific in identifying acute heart damage?
1. troponin
2. CPK
3. CK-MB
4. cholesterol - correct answer✔✔Answer: 1
Rationale 1: Troponin is primarily located in cardiac muscle & can indicate myocardial
infarction or unstable angina. Troponin elevates at two to four hours after myocardial
infarction.
Rationale 2,3: CPK & CK-MB will elevate with myocardial damage, but will take longer to
rise & are not as specific as troponin.
Rationale 4: Cholesterol level is not helpful in diagnosis of myocardial damage.
The nurse realizes that the pt in the critical care area with ventricular tachycardia will
require which action? Select all that apply.
1. immediate assessment & probable emergency intervention by the nurse
2. cardioversion, if sustained & symptomatic
3. probable administration of a potassium channel blocker
4. close observation for one hour prior to calling the physician
5. defibrillation to convert the rhythm in the awake pt - correct answer✔✔Correct Answer:
1,2,3
Rationale 1: The nurse should immediately assess the pt to see how the potentially life-
threatening rhythm is being tolerated.
Rationale 2: The nurse should be prepared to cardiovert the pt in ventricular tachycardia
with a pulse according to standing prescriptions. The nurse in critical care needs to be
, aware of standing prescriptions for each pt prior to an emergent event & needs to have the
necessary emergency equipment & meds ready.
Rationale 3: Class III antidysrhythmic meds (potassium channel blockers) are typically
administered.
Rationale 4: Observation prior to calling a physician is not an appropriate action when a
potentially life-threatening rhythm is identified.
Rationale 5: Defibrillation is only conducted in ventricular tachycardia when the pt is
pulseless; otherwise, time is taken to synchronize for cardioversion.
Which is the priority nursing intervention for a pt with a junctional escape rhythm?
1. Assess the pt for symptoms associated with this rhythm.
2. Contact the physician immediately for emergency orders.
3. Eliminate caffeine from the diet.
4. Prepare for a pacemaker insertion. - correct answer✔✔Answer: 1
Rationale 1: Junctional escape rhythms may be monitored if the pt is not symptomatic. It is
most important to assess the pt to see how they are affected by the rhythm.
Rationale 2: Then, calling the physician to report the rhythm may be appropriate.
Rationale 3: Eliminating caffeine is not an appropriate action for this pt with a junctional
escape rhythm. No indication of symptoms relating to the rhythm was given.
Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this pt
with a junctional escape rhythm. No indication of symptoms relating to the rhythm was
given
Sinus bradycardia (rate 56 bpm) is identified in a sleeping pt on telemetry. Which is the
priority nursing action?
1. Awaken the pt & see how the heart rate responds.
2. Call the physician & report this dysrhythmia.
3. Check the medication administration record & see if there is a PRN medication that will
improve this rhythm.
4. Call for an immediate 12-lead electrocardiogram (ECG). - correct answer✔✔Answer: 1
detailed answers
The nurse is caring for an adult pt who is admitted with chest pain that began four hours
ago. Which test will be most specific in identifying acute heart damage?
1. troponin
2. CPK
3. CK-MB
4. cholesterol - correct answer✔✔Answer: 1
Rationale 1: Troponin is primarily located in cardiac muscle & can indicate myocardial
infarction or unstable angina. Troponin elevates at two to four hours after myocardial
infarction.
Rationale 2,3: CPK & CK-MB will elevate with myocardial damage, but will take longer to
rise & are not as specific as troponin.
Rationale 4: Cholesterol level is not helpful in diagnosis of myocardial damage.
The nurse realizes that the pt in the critical care area with ventricular tachycardia will
require which action? Select all that apply.
1. immediate assessment & probable emergency intervention by the nurse
2. cardioversion, if sustained & symptomatic
3. probable administration of a potassium channel blocker
4. close observation for one hour prior to calling the physician
5. defibrillation to convert the rhythm in the awake pt - correct answer✔✔Correct Answer:
1,2,3
Rationale 1: The nurse should immediately assess the pt to see how the potentially life-
threatening rhythm is being tolerated.
Rationale 2: The nurse should be prepared to cardiovert the pt in ventricular tachycardia
with a pulse according to standing prescriptions. The nurse in critical care needs to be
, aware of standing prescriptions for each pt prior to an emergent event & needs to have the
necessary emergency equipment & meds ready.
Rationale 3: Class III antidysrhythmic meds (potassium channel blockers) are typically
administered.
Rationale 4: Observation prior to calling a physician is not an appropriate action when a
potentially life-threatening rhythm is identified.
Rationale 5: Defibrillation is only conducted in ventricular tachycardia when the pt is
pulseless; otherwise, time is taken to synchronize for cardioversion.
Which is the priority nursing intervention for a pt with a junctional escape rhythm?
1. Assess the pt for symptoms associated with this rhythm.
2. Contact the physician immediately for emergency orders.
3. Eliminate caffeine from the diet.
4. Prepare for a pacemaker insertion. - correct answer✔✔Answer: 1
Rationale 1: Junctional escape rhythms may be monitored if the pt is not symptomatic. It is
most important to assess the pt to see how they are affected by the rhythm.
Rationale 2: Then, calling the physician to report the rhythm may be appropriate.
Rationale 3: Eliminating caffeine is not an appropriate action for this pt with a junctional
escape rhythm. No indication of symptoms relating to the rhythm was given.
Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this pt
with a junctional escape rhythm. No indication of symptoms relating to the rhythm was
given
Sinus bradycardia (rate 56 bpm) is identified in a sleeping pt on telemetry. Which is the
priority nursing action?
1. Awaken the pt & see how the heart rate responds.
2. Call the physician & report this dysrhythmia.
3. Check the medication administration record & see if there is a PRN medication that will
improve this rhythm.
4. Call for an immediate 12-lead electrocardiogram (ECG). - correct answer✔✔Answer: 1
