Cardiac Disorders NCLEX Questions

Question 1 of 5

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?

A. Apical pulse rate of 110 and 4+ pitting edema of feet.B. Thick white sputum and crackles that clear with cough.C. The client sleeping with no pillow and eupnea.D. Radial pulse rate of 90 and CRT less than three (3) seconds.

Correct Answer: A

Rationale: CHF exacerbation causes fluid overload, leading to tachycardia (apical pulse 110) and severe edema (4+ pitting,
A). Thick sputum/crackles (
B) suggest pneumonia, sleeping flat with eupnea (
C) is unlikely, and normal CRT (
D) doesn’t reflect CHF severity.

Question 2 of 5

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

A. Sponge the client's forehead.B. Obtain a pulse oximetry reading.C. Take the client's vital signs.D. Assist the client to a sitting position.

Correct Answer: D

Rationale: Gasping, clamminess, and cyanosis indicate acute pulmonary edema. Sitting upright (
D) improves breathing by reducing preload. Sponging (
A), pulse oximetry (
B), and vital signs (
C) are secondary to positioning.

Question 3 of 5

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?

A. Instruct the client to take a cough suppressant if a cough develops.B. Teach the client how to prevent orthostatic hypotension.C. Encourage the client to eat bananas to increase potassium level.D. Explain the importance of taking the medication with food.

Correct Answer: B

Rationale: ACE inhibitors cause hypotension, so teaching prevention of orthostatic hypotension (
B) is critical. Cough suppressants (
A) are inappropriate for ACE inhibitor cough, bananas (
C) are unnecessary unless hypokalemia exists, and food (
D) is not required.

Question 4 of 5

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?

A. The client diagnosed with congestive heart failure who is being discharged in the morning.B. The client who is having frequent incontinent liquid bowel movements and vomiting.C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.D. The client who is complaining of chest pain on inspiration and a nonproductive cough.

Correct Answer: C

Rationale: Tachycardia, tachypnea, and hypotension (
C) suggest instability, requiring experienced nursing care. Discharging CHF (
A), incontinence/vomiting (
B), and pleuritic pain (
D) are less acute.

Question 5 of 5

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)?

A. Creatine kinase (CK-MB).B. Lactate dehydrogenase (LDH).C. Troponin.D. White blood cells (WBCs).

Correct Answer: C

Rationale: Troponin (
C) rises within 3–4 hours post-MI, making it the earliest marker. CK-MB (
A) rises in 4–6 hours, LDH (
B) in 24–48 hours, and WBCs (
D) are nonspecific.

Cardiac Disorders NCLEX Questions | Nurselytic

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