NCLEX-PN
Pediatric Cardiac Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
Correct Answer: A
Rationale: Muffled heart sounds (
A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (
B) is normal, bounding pulses (
C) are unrelated, and friction rub (
D) is expected.
Question 2 of 5
The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: Increased pain in pericarditis may indicate complications like tamponade. Assessing for cardiac complications (
C) is the priority. Oxygen (
A), urinary output (
B), and spirometry (
D) are secondary.
Question 3 of 5
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
Correct Answer: B
Rationale: Mitral valve vegetations can embolize to the brain, causing a stroke (
B). PE (
A) is right-sided, hemoptysis (
C) is not typical, and DVT (
D) is unrelated to embolization.
Question 4 of 5
The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Post-pericardiocentesis, monitor vital signs (
A), heart/lung sounds (
B), fluid output (
C), and rhythm (
D) to detect complications. Supine position (E) is not required; semi-Fowler’s is preferred.
Question 5 of 5
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first?
Correct Answer: D
Rationale: Asking why the client stopped (
D) is open-ended, identifying barriers like side effects (
B) or asymptomatic disease (
C). Financial issues (
A) are secondary.