Questions 37

NCLEX-PN

NCLEX-PN Test Bank

Pediatric Cardiac Disorders NCLEX Questions Quizlet Questions

Extract:


Question 1 of 5

The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply.

Correct Answer: A,E,F

Rationale: Monitoring BP/apical rate (
A), anticoagulation status (E), and neurological status (F) address AF-related perfusion risks (clots, stroke). I/O (
B) is for fluid status, HOB elevation (
C) is for CHF, and Buerger Allen (
D) is for PAD.

Question 2 of 5

Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.

Correct Answer: A,B,C

Rationale: Valvular disease causes fluid overload, leading to PND (
A), orthopnea (
B), and cough (
C). Pericardial rub (
D) and pulsus paradoxus (E) are specific to pericarditis/tamponade.

Question 3 of 5

The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first?

Correct Answer: D

Rationale: Crushing chest pain suggests ischemia; sitting down (
D) reduces oxygen demand. Code Blue (
A), telemetry (
B), and pulse (
C) follow if pain persists.

Question 4 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 5 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.

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