NCLEX-PN
Cardiac Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?
Correct Answer: C
Rationale: Numbness (
C) suggests vascular compromise or nerve compression, requiring immediate intervention. Keeping the leg straight (
A), intact dressing (
B), and strong pulse (
D) are expected.
Question 2 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?
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 3 of 5
If the client's severe chest pain is typical of other people who experience myocardial infarction (MI), the client is most likely to tell the nurse that the discomfort radiates to which area?
Correct Answer: D
Rationale: MI pain typically radiates to the shoulder, arm, or jaw due to referred pain from cardiac ischemia.
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
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.