NCLEX-PN
Pediatric Cardiac Disorders NCLEX Questions Quizlet Questions
Extract:
Question 1 of 5
The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?
Correct Answer: C
Rationale: Leaning forward (
C) enhances auscultation of a pericardial friction rub, which may be positional. Notifying HCP (
A), documenting resolution (
B), or chest tube (
D) are premature or unrelated.
Question 2 of 5
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse?
Correct Answer: D
Rationale: Cool, clammy, diaphoretic skin (
D) indicates cardiogenic shock or sympathetic response, requiring immediate intervention. Pulses (
A), SpO2 (
B), and urine output (
C) are normal.
Question 3 of 5
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (
A) detects fluid retention, pulse counting (
B) ensures digoxin safety, and removing salt (
C) reduces sodium intake. Dark urine (
D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
Question 4 of 5
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
Correct Answer: A
Rationale: Elevated BNP (
A) is specific to heart failure, reflecting ventricular stress. CK-MB (
B) indicates myocardial infarction, D-dimer (
C) suggests clotting, and V/Q scan (
D) is for pulmonary embolism.
Question 5 of 5
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
Correct Answer: D
Rationale: Positioning for an x-ray (
D) is within the UAP’s scope and safe. Smoking (
A) is inappropriate, ICU transport (
B) requires nursing judgment, and discharge teaching (
C) is a nursing responsibility.