NCLEX-PN
Cardiac Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.
Question 2 of 5
The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
Question 3 of 5
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
Correct Answer: B
Rationale: The normal clotting time is 9 to 12 minutes. A prolonged clotting time suggests a bleeding tendency, so the client should be observed for signs of bleeding, such as ecchymotic areas. Blood clots would occur with a shorter clotting time. Jaundice is related to liver damage or red blood cell breakdown. Infection is associated with low white blood cell counts.
Question 4 of 5
Which prothrombin time value would be considered normal for a client who is receiving warfarin (Coumadin)?
Correct Answer: B
Rationale: For a client receiving warfarin, the prothrombin time should be 1.5 to 2 times the normal value (11 to 12.5 seconds). Twenty seconds falls within this therapeutic range. Twelve seconds is normal for someone not on warfarin. Sixty seconds is normal for a partial thromboplastin time (PTT) test, and 98 seconds would be therapeutic for heparin, not warfarin.
Question 5 of 5
An adult who is receiving heparin asks the nurse why it cannot be given by mouth. The nurse responds that heparin is given parenterally because:
Correct Answer: AUG
Rationale: Heparin is a protein and is destroyed by gastric secretions, requiring parenteral administration (intravenously or subcutaneously). It does not irritate the gastric or intestinal lining, and while parenteral administration allows faster therapeutic levels, the primary reason is its destruction in the stomach.