NURS NCLEX Exam 2-with 100% Verified Solutions

NURS NCLEX Exam 2-with 100% Verified Solutions
Cardiac
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours
before the procedure and for 48 hours after the procedure?
Metformin
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for
2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the
subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level
is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the
basis of these findings, the nurse would anticipate that the client is at risk for which problem?
Acute Kidney Injury
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes
are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The
overall heart rate is 64 beats/minute. Which action should the nurse take?
Continue to monitor
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse
sees no electrocardiographic complexes on the screen. Which is the priority nursing action?
Check the client's status and lead placement.
The nurse is evaluating a client's response to cardioversion. Which assessment would be the
priority?
Status of airway
The nurse is caring for a client who has just had implantation of an automatic internal
cardioverter-defibrillator. The nurse should assess which item based on priority?
Activation status of the device, heart rate cutoff, and number of shocks it is programmed
to deliver
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR
interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR
intervals are regular. How should the nurse correctly interpret this rhythm?
Sinus tachycardia
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing
unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the
nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission.
How should the nurse correctly interpret the client's neurovascular status?
The neurovascular status is normal because of increased blood flow through the leg.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat
cardiac tamponade. Which observation would indicate that the procedure was effective?
A rise in blood pressure
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily.
Which statement by the client indicates the need for further teaching?
"My spouse told me that since I have developed this problem, we are going to stop
walking in the mall every morning."
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which
assessment finding indicates the presence of this complication?
Muffled or distant heart sounds
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about
home care management and self-care management. Which statement, if made by the client,
indicates a need for further instruction?
"I need to be sure that I elevate my leg above the level of my heart for at least an hour
every day."
The nurse is providing instructions to a client with a diagnosis of hypertension regarding highsodium items to be avoided. The nurse instructs the client to avoid consuming which item?
Antacids
The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse
should plan to provide which instruction to the client?
Stop smoking because it causes cutaneous blood vessel spasm
The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown
occurred over the varicosities as a result of secondary infection. Which is a priority intervention?
Elevate the legs higher than the heart
The nurse in the medical unit is reviewing the laboratory test results for a client who has been
transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay
was performed while the client was in the ICU. The nurse determines that this test was
performed to assist in diagnosing which condition?
Myocardial infarction
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor.
The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of
150 beats/minute. The nurse should next assess the client for which finding?
Hypotension
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure.
Which assessment component would elicit specific information regarding the client's left-sided
heart function?
Listening to lung sounds
The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse
indicates an understanding of a PR interval of 0.20?
"This is a normal finding."
The nurse in the medical unit is assigned to provide discharge teaching to a client with a
diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to
minimize the effects of the disease process. The client continually changes the subject during
the teaching session. The nurse interprets that this client's behavior is most likely related to
which problem?
An attempt to ignore or deny the need to make lifestyle changes

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