NCLEX-PN
Pediatric Cardiac Disorders NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?
Correct Answer: A
Rationale: An S3 heart sound post-MI (
A) indicates heart failure or fluid overload, requiring immediate assessment. Edema (
B) is chronic, 94% SpO2 (
C) is stable, and elevated creatinine (
D) is expected in CRF.
Question 2 of 5
Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?
Correct Answer: B
Rationale: Mitral insufficiency (regurgitation) causes a holosystolic murmur at the apex (
B) due to backflow. S1/S2 snap (
A) is mitral stenosis, ejection click (
C) is aortic/pulmonic, and high-pitched sound (
D) is nonspecific.
Question 3 of 5
The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement?
Correct Answer: A
Rationale: P wave before QRS at rate 78 (
A) is normal sinus rhythm, requiring documentation. ECG (
B), digoxin (
C), and enzymes (
D) are unnecessary.
Question 4 of 5
Which laboratory data confirm the diagnosis of congestive heart failure?
Correct Answer: D
Rationale: Elevated BNP (
D) is specific for CHF, reflecting ventricular stress. CXR (
A) shows fluid but is not diagnostic, liver tests (
B) and BUN (
C) are nonspecific.
Question 5 of 5
The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instruction(s) should the nurse teach the client?
Correct Answer: A,B,C
Rationale: Instructing to call HCP for chest pain (
A), discussing sexual activity (
B), and explaining nitroglycerin (
C) ensure safety and recovery. HOB elevation (
D) is for CHF, not MI.