Pediatric Cardiac Disorders NCLEX Questions

Extract:

Question 1 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 2 of 5

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of 'decreased cardiac output related to inability of the heart to pump effectively' is written. Which short-term goal would be best for the client?

A. The client will be able to ambulate in the hall by date of discharge. B. The client will have an audible S1 and S2 with no S3 heard by end of shift. C. The client will turn, cough, and deep breathe every two (2) hours. D. The client will have a SaO2 reading of 98% by day two (2) of care.

Correct Answer: B

Rationale: Absence of an S3 heart sound (
B) indicates improved cardiac function, directly addressing decreased cardiac output. Ambulation (
A) is long-term, turning/coughing (
C) is an intervention, and SaO2 of 98% (
D) is less specific to cardiac output.

Question 3 of 5

The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first?

A. Administer epinephrine IVP. B. Prepare to defibrillate the client. C. Call a STAT code. D. Start cardiopulmonary resuscitation (CPR).

Correct Answer: C

Rationale: Ventricular fibrillation is a code situation. Calling a STAT code (
C) initiates the response team. Epinephrine (
A), defibrillation (
B), and CPR (
D) follow code activation.

Question 4 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?

A. Document this as normal sinus rhythm. B. Request a 12-lead electrocardiogram. C. Prepare to administer the cardiotonic digoxin PO. D. Assess the client's cardiac enzymes.

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 5 of 5

The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instruction(s) should the nurse teach the client?

A. Call the health care provider (HCP) if any chest pain happens. B. Discuss when the client can resume sexual activity. C. Explain the pharmacology of nitroglycerin tablets. D. Encourage the client to sleep with the head of the bed elevated.

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.

Pediatric Cardiac Disorders NCLEX Questions | Nurselytic

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