Cardiac Nclex Question And Correct Answers

CARDIAC NCLEX QUESTION AND CORRECT ANSWERS B A. INCORRECT: Turning, coughing, and deep breathing should be performed every 2 hr to promote oxygenation and circulation. B. CORRECT: Providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness. C. INCORRECT: This is not an adequate inspired air volume to promote effective oxygenation. D. INCORRECT: This intervention is non-therapeutic communication. A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, and then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia. B A. INCORRECT: A trace of bloody drainage on the dressing is an expected finding and does not require immediate concern. B. CORRECT: Capillary refill greater than 2 to 4 seconds is outside the expected reference range and should be reported to the provider. C. CORRECT: Mottled appearance of the affected extremity is an unexpected finding and should be reported to the provider. D. INCORRECT: Pain that is decreased following IV bolus analgesia is an expected finding and does not require immediate concern. E. INCORRECT: Pulse of 2+ in the affected extremity is an expected finding and does not require immediate concern. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb D A. INCORRECT: Reddening (rubor) of a leg affected by peripheral artery disease occurs when it is placed in a dependent position. B. INCORRECT: Pulses are decreased or absent in the feet in cases of peripheral artery disease. C. INCORRECT: Toenails are thickened in cases of peripheral artery disease. D. CORRECT: A client who has peripheral artery disease may report that numbness or burning pain in the extremity ceases with rest (intermittent claudication). A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg S3: Remains constant through respiration, possible sign of ventricular failure When auscultating heart, extra heart sound at apex after S2 is heard throughout respiratory cycle: Morphine: Priority is relieving pain ER woman arrives with radiating chest pain with orders of morphine, 4L of O2, chest radiograph and morphine. Which should nurse do first: Position electrodes; take vitals; administer Morphine; Obtain drug history Client with polysubstance abuse is admitted to telemetry unit for MI: nurse should from first to last: B Precursor to v-tach and v-fib. An occasional one is ok, but 5 per min in post-MI pt, Dr should be notified immediately. Tx: Usually administering Lidocaine While caring for pt with MI, pt has 8 PVCs in one minute. What should the nurse do first: A. Increase IV rate; B.Notify DR; C.Increase O2; D. Administer analgesic B Which of the following is the most appropriate diet for a client during acute phase of MI? A. Liquids B. Small, easily digested meals. C. Three regular meals per day D. NPO A Observing chest pain is priority since closure can reoccur. After administration of TPA, nurse should: A. Observe pt for chest pain; B. monitor fever; C. review ECG; D. auscultate breath sounds B Client in ER has indigestion, history of HTN, and family history of MI. After connecting him to ECG, administering 2L O2, What should the nurse do next: A. Call physician B. Start IV infusion C. Obtain portable chest Xray D. Draw blood labs A Resp status will be improved after increased CO Primary goal of nursing care for pt with HF and pulmonary edema: A. Increase CO; B. Improve resp. status; C. Decrease peripheral edema; D. Enhance comfort C Basic Principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. • Pt has risk factors for CAD. Nurse can best reinforce new adaptive behaviors by: A. Explain effects of risk behavior; B. Withhold praise till new behavior is well established; C. Reward pt whenever acceptable behavior is performed; D. Instill mild fear A Observing chest pain is priority since closure can reoccur. After administration of TPA, nurse should: A. Observe pt for chest pain; B. monitor fever; C. review ECG; D. auscultate breath sounds 1. Rapid filling of the ventricle causes vasodilation that is auscultated as S3. Increased atrial contraction or systemic hypertension can result in a fourth heart sound. Aortic valve malfunction is heard as a murmur. Which of the following complications is indicated by a third heart sound (S3)? 1. Ventricular dilation 2. Systemic hypertension 3. Aortic valve malfunction 4. Increased atrial contractions 1. The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn't function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right sided heart failure. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? 1. Left-sided heart failure 2. Pulmonic valve malfunction 3. Right-sided heart failure 4. Tricupsid valve malfunction 3 Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI What is the first intervention for a client experiencing MI? 1. Administer morphine 2. Administer oxygen 3. Administer sublingual nitroglycerin 4. Obtain an ECG 1. Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload). Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? 1. Beta-adrenergic blockers 2. Calcium channel blockers 3. Narcotics 4. Nitrates A,B,C,E A. CORRECT: Processed cheese contains 800 mg sodium per 2 oz. B. CORRECT: A hot dog contains 615 mg sodium. C. CORRECT: Canned tuna contains 350 mg sodium per 3 oz. D. INCORRECT: Lean meats, fish, and poultry contain 30 to 90 mg of sodium per 3 oz. E. CORRECT: Lean, baked ham contains 1,020 mg sodium per 3 oz. 3. A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? (Select all that apply.) A. Cheddar cheese, 2 oz B. Hot dog C. Canned tuna, 3 oz D. Roast chicken breast, 3 oz E. Baked ham, 3 oz A,B,E A. CORRECT: Tachypnea is an expected finding in a client who has pulmonary edema. B. CORRECT: A persistent cough with pink, frothy sputum is an expected finding in a client who has pulmonary edema. C. INCORRECT: Decreased urinary output is an expected finding in a client who has pulmonary edema. D. INCORRECT: Pink, frothy sputum is an expected finding in a client who has pulmonary edema. E. CORRECT: Orthopnea is an expected finding in a client who has pulmonary edema. A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea A, B, E A. CORRECT: Dyspnea is a clinical manifestation of right-sided valvular heart disease. B. CORRECT: A client's report of fatigue is a clinical manifestation of right-sided valvular heart disease. C. INCORRECT: A normal or rapid pulse and an irregularly irregular rhythm are clinical manifestations of right-sided valvular heart disease. D. INCORRECT: A pleural friction rub is a manifestation of pleurisy or pneumonia. E. CORRECT: Peripheral edema is a clinical manifestation of right-sided valvular heart disease. A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema B A. INCORRECT: A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not improve blood flow in the coronary arteries. B. CORRECT: Surgery is indicated for older adult clients when clinical manifestations interfere with activities of daily living. C. INCORRECT: Surgical interventions can improve the client's quality of life, but they will not necessarily prolong life. D. INCORRECT: A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not reverse the damage that has already occurred to the valve. A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following is an appropriate response by the nurse? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C. "This will prolong your mother's life." D. "This will reverse the effects to the damaged area." 3 Complication of balloon valvuplasty is a stroke Client has returned from the cardiac cath lab after a balloon valuloplasty for mitral stenosis. Which of the following requires immediate action? 1. low grade 1 mitral regurgiation murmur 2. 94% SpO2 on 2 L O2 3. Client becomes somnolent 4. Urine output decreased from 60 ml/hr to 40 ml/hr over the last hour 3 Assessment of circulatory status, including observation of puncture site is primary importance Most important initial postprocedure nursing assessment for a client who has had a cardiac cath? 1. lab values 2. neuro checks q 15 minutes 3. observe puncture site for swelling and bleeding 4. monitor skin warmth and turgor