NCLEX Week 2 Questions

NCLEX Week 2 Questions

• The nurse is caring for a client diagnosed with an anterior myocardial infarction
• days ago. Upon assessment, the nurse identifies a new systolic murmur at the

apex. The nurse should first:

• Assess for changes in vital signs.
• Draw an arterial blood gas.
• Evaluate heart sounds with the client leaning forward.
• Obtain a 12 Lead electrocardiogram.

Answer: A

Rationale: Vital sign changes will reflect the severity of the sudden drop in cardiac

output: decrease in blood pressure, increase in heart rate, and increase in

respirations. ABG, heart sounds,are not the ways to detect severity of a murmur.A 12 lead electrogram would work in the case of an MI but not for the murmur.

• A client with acute chest pain is receiving I.V. morphine sulfate. Which of the

following results are intended effects of morphine in this client? Select all that apply.

• Reduces myocardial oxygen consumption.
• Promotes reduction in respiratory rate.
• Prevents ventricular remodeling.
• Reduces blood pressure and heart rate.
• Reduces anxiety and fear.

Answer: A, D, E

Rationale: Morphine sulfate acts as an analgesic and sedative. It reduces blood

pressure, and heart rate by reducing the oxygen consumption of the myocardium.Morphine helps to reduces anxiety and fear. Its sedative effects help do this by slowing the heart rate. B, and C are not effects of morphine.

• A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The

dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? Round your answer to a whole number.24mL/H

Rational: 25000/500=50 1200/50=24

• An older client has chest pain and shortness of breath. The health care provider

(HCP) prescribes nitroglycerin tablets. What should the nurse instruct the client to do?

• Put the tablet under the tongue until it is absorbed.
• Swallow the tablet with 120 mL of water.
• Chew the tablet until it is dissolved.
• Place the tablet between his cheek and gums.

Answer: C

Rationale: The client is having symptoms of a MI. Therefore, we need a fast-acting medication like nitroglycerin to prevent any further issues from happing. The nitroglycerin tablet will be absorbed fastest if the client chews the tablet. Thus making, A, B, and D the wrong answers.

5.The Nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?

• BP 110/62 mm Hg, atrial fibrillation with HR 82, bibasilar crackles.
• Confusion, urine output 15 mL over the last 2 hours, orthopnea.
• SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower

extremities.

• Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

Answer: B

Rationale: A low urine output and confusion are signs of decreased tissue

perfusion, and signs of heart failure. Orthopnea is a sign of left-sided heart failure.HR and BP are stable, in answer and A, so this is not a priority. Edema is not excessive in C, so this would not be a priority answer, and weight gain of 1kg/day would be a sign, but is not priority, and dyspnea w/ exercise is expected.

• The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the

monitor. The nurse should first:

• Administer atropine 0.5mg IV push.
• Auscultate for abnormal heart sounds.

• Prepare for transcutaneous pacing.
• Take the client’s blood pressure.

Answer: D

Rationale: The nurse should take the client’s blood pressure first to assess for hypotension. The nurse shouldn’t administer medication or prepare for transcutaneous pacing without getting more information from a detailed assessment of the client. The nurse should listen to the client’s apical pulse after getting the blood pressure. This is part of the detailed assessment that must be preformed on the client due to the rapid drop in the HR the client is experiencing.

7.When preparing a client for cardiac angiogram, what actions should the nurse take? Select all that apply.

• Determine if the client has an allergy to liquid contrast material.
• Inform the client that an intravenous infusion will be started before the

procedure.

• Remind the client to have nothing to eat or drink 8 hours before the

procedure.

• Instruct the client to remain still during the procedure.
• Explain that the client will receive a fast-acting anesthetic.

Answer: A, C, D, E

Rationale: A cardiac angiogram is a procedure that injects dye into the arteries to visualize them better. The client should be assessed for allergies such as shellfish because it can cause a reaction to happen when injected with the dye. The client must be NPO for 8 hours before the procedure because some foods, and drinks can must with the heart, and the risk of aspiration. The client must also be instructed to remain still and hold their breath or cough. The site where the catheter will be inserted will be numbed.The IV infusion is not infused before the procedure it is preformed during because of how quickly it is metabolized by the body.

• A client is admitted with a myocardial infarction and atrial fibrillation. While

auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the

respiratory cycle. The nurse should document these findings as:

• Heart rate irregular with S3.
• Heart rate irregular with S4.
• Heart rate irregular with aortic regurgitation.
• Heart rate irregular with mitral stenosis.

Answer: A

Rationale: A third heart sound is a normalin young adults but it can represent a pathologic process in happening within an older adult. The sound is caused by rapid left ventricular filling. It may be produced when the heart is already overfilled or weak. It occurs immediately after S2, and can be a sign that other issues are happening within the body.

• A 60-year old comes into the emergency department with crushing substernal

chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should

first:

• Administer the morphine.
• Obtain a 12-lead ECG.
• Obtain the blood work.
• Prescribe the chest radiograph.

Answer: A