NCLEX-PN
Cardiac Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?
Correct Answer: C
Rationale: Leg movements (
C) prevent DVT in MI patients on bedrest, so praising the UAP is appropriate. Stopping (
A), reporting (
B), or ignoring (
D) are incorrect.
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
When the nurse is about to administer digoxin to a client, the client says, 'I think I need to see the eye doctor. Things seem to look kind of green today.' The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
Correct Answer: B
Rationale: Visual disturbances, such as seeing a green or yellow halo, are signs of digoxin toxicity. The nurse should withhold the medication and report to the charge nurse for further evaluation.
Question 4 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 5 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.