Priority Cardiovascular NCLEX Questions

Priority Cardiovascular NCLEX Questions Leave the first rating Students also studied Terms in this set (10) Science MedicineEmergency Medicine Save Cardiovascular Priority Questions 80 terms abbeykaitlyn1 Preview Cardiac NCLEX Questions 23 terms onealkayleePreview Prioritization NCLEX questions 28 terms madisoncastello Preview

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• The nurse has applied the patch electrodes of an

automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next?

• Administer rescue breathing during the defibrillation.
• Perform cardiopulmonary resuscitation (CPR) for 1

minute before defibrillating.

• Charge the machine and immediately push the

"discharge" buttons on the console.

• Order any personnel away from the client, charge the

machine, and defibrillate through the console.

• Order any personnel away from the client, charge the machine, and defibrillate

through the console.

Rationale: If the AED advises to defibrillate, the nurse or rescuer orders all

persons away from the client, charges the machine, and pushes both of the "discharge" buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as "hands-off" defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.

• A client demonstrating unstable ventricular tachycardia

(VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously.Which item should the nurse caring for the client immediately obtain?

• A pacemaker
• A defibrillator
• A second dose of lidocaine
• An electrocardiogram machine
• A defibrillator

Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.

• On answering the emergency call light, the nurse finds

a new postoperative client experiencing tachycardia and tachypnea, and the unlicensed assistive person reports that the client's blood pressure is 88/60 mm Hg. Which action should the nurse implement first?

• Recheck the client's blood pressure.
• Check the client's hourly urine output.
• Check the intravenous (IV) site for infiltration.
• Place the client in a modified Trendelenburg's position.
• Place the client in a modified Trendelenburg's position.

Rationale: The client is exhibiting signs of shock and requires emergency

intervention. The nurse would immediately place the client in a modified Trendelenburg's position. This position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's volume status by assessing the urine output and whether the IV is infusing. The nurse should obtain all this information quickly and then call the health care provider. The nurse would also monitor the client's blood pressure, but retaking the blood pressure as a first action would delay necessary and potentially lifesaving intervention.

• The nurse is teaching a client with a diagnosis of

cardiomyopathy about home care safety measures.Which instruction is most important for the nurse to include?

• Reporting pain
• Appropriate vasodilator administration
• Avoiding over-the-counter medications
• Moving slowly from a sitting to a standing position
• Moving slowly from a sitting to a standing position

Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a

result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety.

• A client with arterial leg ulcers tells the nurse, "I'm so

discouraged. I have had this pain for more than a year now. The pain never seems to go away. I can't do anything, and I feel as though I'll never get better." The nurse determines that which is the priority client concern?

• Fatigue
• Uneasiness
• Chronic pain
• An acute illness
• Chronic pain

Rationale: The major focus of the client's complaint is the experience of pain. Pain that has a duration of more than 3 months is defined as chronic pain and does not indicate an acute illness. There are no data in the question that indicate fatigue or uneasiness.

• A client diagnosed with valvular heart disease is at risk

for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?

• Heart rate
• Breath sounds
• Blood pressure
• Activity tolerance
• Breath sounds

Rationale: Breath sounds are the best way to assess for the onset of heart failure.The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.

• The nurse should expect a client experiencing an acute

myocardial infarction to manifest which pattern first on the electrocardiogram?

• Absent P waves
• T-wave elevation
• An abnormal Q wave
• ST segment elevation
• ST segment elevation

Rationale: ST segment elevation usually occurs immediately or during the early

stages of acute myocardial infarction. Absent P wave or P waves that are difficult to discern are noted in atrial fibrillation. T-wave inversion and abnormal Q-wave changes occur later, within hours to several days after the acute myocardial infarction.

Which is the priority nursing assessment for a client after a cardiac catheterization?

• Temperature
• Urine output
• Potassium level
• Catheter insertion site
• Catheter insertion site

Rationale: During the post-cardiac catheterization period, priorities of nursing care include frequent monitoring of the blood pressure and pulse. The catheter insertion site is checked frequently for signs of bleeding and swelling. Distal pulses also are assessed. Temperature, urine output, and potassium level also should be monitored, but they are not the priority of the items identified in the options.The nurse is caring for a client with a diagnosis of angina.Which data should the nurse obtain immediately when the client begins to experience chest pain?

• Blood pressure
• Apical heart rate
• Whether nausea is present
• Location and intensity of pain
• Location and intensity of pain

Rationale: The nurse must assess the pain by requesting a description of intensity, location, duration, and quality of the pain. Although the nurse may check the client's vital signs and check for symptoms of nausea, assessment of the pain is the priority.The nurse caring for a client who has been treated with cardioversion will perform which assessment first?

• Blood pressure
• Status of airway
• Oxygen flow rate
• Level of consciousness
• Status of airway

Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority.