nclex question
halago73
CARDIOVASCULAR1.pdf
1- An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is
the priority assessment the nurse should perform?
1.
Assess for dry, scaly skin on the lower legs
2.
Assess for presence or absence of hair growth on lower extremities
3.
Check for presence and quality of posterior tibial and dorsalis pedis pulses
4.
Obtain a dietary history
2- A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to
this medication. Which statement by the client indicates that the teaching has been
effective?
1.
"I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out."
2.
"I can still take this with my vardenafil prescription."
3.
"I can take up to 3 pills in a 15-minute period if I am experiencing chest pain."
4.
"I should stop taking the pills if I experience a headache."
3- A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the
nurse would be concerning in relation to this new medication? Select all that apply.
1.
Blood pressure of 140/84 mm Hg
2.
Heart rate of 98/min
3.
Platelet count of 200,000/mm3 (200 x 109/L)
4.
Report of Ginkgo biloba use
5.
Report of peptic ulcer disease
4- An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which
situation would warrant intervention by the experienced nurse?
1.
Nurse has client lie supine for 5-10 minutes prior to starting procedure
2.
Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding
3.
Nurse starts by measuring BP and heart rate (HR) with the client standing
4.
Nurse takes BP and HR after standing at 1- and 3-minute intervals
5- The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the
PT/INR is 2 times the control value. What action does the nurse anticipate?
1.
Clarify vegetable consumption with client
2.
Decrease the heparin rate
3.
Decrease the warfarin dose
4.
Obtain an order for vitamin K injection
6- The nurse is reviewing the medication administration record of a client with atrial
fibrillation. Which of the following should the nurse monitor before giving these
medications? Select all that apply. See medication administration record below.
1.
Digoxin level
2.
Glucose
3.
INR
4.
Platelet count
5.
Serum potassium
7- A client with chronic stable angina is reporting chest pain. The nurse notices that the transdermal nitroglycerin patch that was applied 1 hour ago has peeled off. The client's
vital signs are stable. What is the nurse's priority action?
1.
Administer PRN morphine
2.
Administer PRN sublingual nitroglycerin
3.
Apply a new transdermal nitroglycerin patch
4.
Obtain a 12-lead electrocardiogram
8- The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take?
1.
Administer the next scheduled dose of warfarin
2.
Anticipate infusing fresh, frozen plasma
3.
Call the pharmacy to see if protamine is available
4.
Request a prescription from the health care provider (HCP) for vitamin K
9- The nurse is caring for a client who experienced an anterior wall myocardial infarction 24 hours ago. The nurse recognizes the rhythm on the cardiac monitor as which rhythm?
1.
Premature ventricular contractions
2.
Sinus tachycardia
3.
Ventricular fibrillation
4.
Ventricular tachycardia
10- A client with suspected moderate to large pericardial effusion is admitted for
monitoring. The nurse performs a head-to-toe assessment. Which of these findings
indicate likely cardiac tamponade and require immediate intervention? Select all that
apply.
1.
Blood pressure of 90/70 mm Hg
2.
Bounding peripheral pulses
3.
Decreased breath sounds on left side
4.
Distant heart tones
5.
Jugular venous distension
11- The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the
monitor. The nurse recognizes it as which rhythm?
1.
Asystole
2.
Atrial fibrillation
3.
Ventricular fibrillation (VF)
4.
Ventricular tachycardia
12- An 80-year-old client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the office nurse?
1.
Dizziness on standing
2.
Fasting blood sugar of 160 mg/dL (8.9 mmol/L)
3.
Presence of muscle cramps
4.
Sunburn
13- A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion
sites. What interventions should the nurse implement? Select all that apply.
1.
Continue heparin infusion and recheck aPTT in 6 hours
2.
Prepare to administer vitamin K
3.
Redraw blood for laboratory tests
4.
Review guidelines for administration of protamine
5.
Stop infusion of heparin and notify the health care provider (HCP)
14- The nurse is discharging a client who has been prescribed warfarin for chronic atrial fibrillation. The nurse should instruct the client to avoid excess or inconsistent intake of
which foods? Select all that apply.
1.
Bananas
2.
Broccoli
3.
Grapefruit juice
4.
Red meat
5.
Spinach
15- The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up?
1.
Abdomen is soft, nondistended, and tender to touch
2.
Blood pressure is 96/66 mm Hg and apical pulse is 112/min
3.
Client rates pain as 4 on a scale of 0-10
4.
Green bile is draining from the nasogastric tube
16- The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation?
1.
30-year-old athlete with a heart rate of 50/min
2.
45-year-old client with a body mass index of 35 kg/m2 and fingerstick glucose of 150 mg/dL
(8.3 mmol/L)
3.
55-year-old client missing all the hair on the lower legs and failing the pinprick test
4.
80-year-old client with a blood pressure of 150/90 mm Hg
17- An 8-month-old infant is scheduled for a femorally inserted balloon angioplasty of a
congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding
should the nurse report to the health care provider that could possibly delay the
procedure?
1.
Auscultation of a loud heart murmur
2.
Infant has been NPO for 4 hours
3.
Infant has severe diaper rash
4.
Slight cyanosis of the nail beds
18- An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?
1.
Nurse carefully auscultates for heart murmurs at Erb's point
2.
Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry
3.
Nurse places client in semi-Fowler's position to assess for jugular venous distension
4.
Nurse positions client supine to assess the point of maximal impulse
19- A client diagnosed with a ST-segment elevation myocardial infarction (STEMI) is receiving an intravenous thrombolytic infusion. In evaluating the client's response to
treatment, which assessment finding by the nurse is the best indicator that reperfusion has
occurred?
1.
Increase in troponin level
2.
Nonsustained ventricular tachycardia
3.
Reduction of chest pain
4.
Return of ST segment to baseline
20- The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching?
1.
"I will call my health care provider if I notice red urine or blood in my stool."
2.
"I will not stop taking dabigatran even if I get a stomachache."
3.
"I will place capsules in my pill box so I will not forget to take a dose."
4.
"I will swallow the capsule whole with a full glass of water."
21- The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should
the nurse implement first?
1.
Assess incision for bleeding or hematoma formation
2.
Auscultate bilateral anterior and posterior lung sounds
3.
Initiate continuous cardiac monitoring
4.
Reestablish IV fluids and postoperative antibiotics
22- The nurse is caring for a client who has been admitted to the hospital for an acute
exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min,
respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports
the diagnosis of acute heart failure exacerbation?
1.
B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L]
2.
Flat jugular veins when seated at a 45-degree angle
3.
Sodium 150 mEq/L [150 mmol/L]
4.
Urine output greater than 100 mL/hr
23- A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What
additional teaching should the nurse include for this client?
1.
Avoid aerobic exercise
2.
Ensure you receive antibiotics prior to dental work
3.
Stay well hydrated and avoid caffeine
4.
Wear a medical alert bracelet
24- The nurse is developing a teaching plan for a 65-year-old African American male client with a BMI of 30 kg/m2 and a strong family history of cardiovascular disease. Which
risk factor for coronary artery disease (CAD) should the nurse focus on during teaching?
1.
Client's BMI of 30 kg/m2
2.
Client's ethnicity
3.
Client's gender
4.
Client's strong family history of cardiovascular disease
25- A client has heart failure and has gained 5 lb (2.26 kg) over the last 3 days. Blood laboratory results from today are shown in the exhibit. What medication administration
does the nurse anticipate?
1.
0.2% intravenous normal saline
2.
Calcium gluconate
3.
Furosemide
4.
Sodium polystyrene
26- The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health
care provider?
1.
Gram-negative infection and positive blood cultures in a client prescribed tobramycin
2.
Serum B-type natriuretic peptide (BNP) 650 pg/mL (650 ng/L) in a client prescribed
furosemide
3.
Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone
4.
Serum sodium 132 mEq/L (132 mmol/L) in a client prescribed IV normal saline solution at
175 mL/hr
27- The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that
teaching has been effective?
1.
"I'm glad that I can continue taking my Ginkgo biloba."
2.
"I will increase my intake of leafy green vegetables."
3.
"I will start applying vitamin E to my chest incision after showering."
4.
"I will shave with an electric razor from now on."
28- A client is admitted to the emergency department after a fall with dizziness and light- headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the
rhythm in the exhibit. The nurse recognizes it as which rhythm?
1.
Complete heart block
2.
1st-degree heart block
3.
Sinus bradycardia
4.
Sinus rhythm
29- A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an
outpatient. The client is embarrassed to talk to the health care provider (HCP) about
resuming sexual relations after an MI. What teaching should the nurse initiate with this
client?
1.
If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for
sexual activity if approved by the HCP
2.
Inform the client that medications such as sildenafil or tadalafil are available as prescriptions
from the HCP
3.
It will be 6 months before the heart is healthy enough for sexual activity
4.
The client will be ready for sexual activity after completion of cardiac rehabilitation
30- The client is scheduled to have a cardiac catheterization. Which findings will cause the nurse to question the safety of the test proceeding? Select all that apply.
1.
Elevated C-reactive protein level
2.
History of previous reaction to IV contrast
3.
Prolonged PR interval on electrocardiogram
4.
Serum creatinine of 2.5 mg/dL (221 µmol/L)
5.
Took metformin today for type 2 diabetes
31- The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?
1.
Glucose 200 mg/dL (11.1 mmol/L)
2.
Hematocrit 38% (0.38)
3.
Potassium 3.4 mEq/L (3.4 mmol/L)
4.
Troponin 0.7 ng/mL (0.7 mcg/L)
32- A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the
nurse suspect as the most likely cause?
1.
Captopril
2.
Carvedilol
3.
Glimepiride
4.
Levothyroxine
33- The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering?
1.
Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily
2.
Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)
3.
Client is receiving vancomycin IV; mild facial flushing noted after 30 minutes
4.
Client with diabetes has insulin glargine prescribed; current blood glucose is 100 mg/dL (5.6
mmol/L)
