NCLEX-PN
Cardiac Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse assessing the client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement first?
Correct Answer: B
Rationale: JVD and hypotension (BP drop to 106/94) suggest cardiac tamponade; notifying the HCP (
B) is urgent. Staying calm (
A), lateral position (
C), and morphine (
D) are secondary.
Question 2 of 5
The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (
A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (
B), potassium (
C), and digoxin level (
D) are routine but secondary to dose error.
Question 3 of 5
Which modification used by the nurse is most appropriate when taking the blood pressure of a client who weighs 250 pounds?
Correct Answer: D
Rationale: An extra-large blood pressure cuff is appropriate for clients with larger arm circumferences, such as those who are obese, to ensure accurate readings. Using the thigh, lying down, or over-inflating the cuff does not address the need for proper cuff size.
Question 4 of 5
According to the nurse, when is the correct time to note the diastolic blood pressure reading?
Correct Answer: B
Rationale: The diastolic blood pressure is recorded at the point when the last loud knocking sound (Korotkoff phase V) is heard, indicating the pressure at which blood flow is fully restored.
Question 5 of 5
When obtaining a health history from this client, which finding strongly suggests that the client is hypertensive? Select all that apply.
Correct Answer: A,C,E
Rationale: Unexplained nosebleeds, waking to urinate at night (nocturia), and dizziness are symptoms associated with hypertension due to increased vascular pressure, kidney effects, and cerebral hypoperfusion, respectively.