NCLEX Review about Cardiac Nursing (46-50)

NCLEX Review about Cardiac Nursing

46. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a) weight loss
b) flat neck and hand veins
c) an increase in blood pressure
d) a decreased central venous pressure (CVP)

47. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?
. 46. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a) weight loss
b) flat neck and hand veins
c) an increase in blood pressure
d) a decreased central venous pressure (CVP)

47. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?

a) dry skin
b) decreased urinary output
c) hyperactive bowel sounds
d) increased specific gravity of the urine

48. A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a:

a) normal level
b) low value that indicates possible gastritis
c) level that indicates a myocardial infarction
d) level that indicates the presence of possible angina

49. A client with atrial fibrillation who is receiving maintainance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders?

a) adding a dose of heparin sodium
b) holding the next dose of warfarin
c) increasing the next dose of warfarin
d) administering the next dose of warfarin

50. A client recently diagnosed with a myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 ml/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain blood pressure. on entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that hte client is most likely

a) hematoma
b) systemic infection
c) electrolyte overload
d) circulatory overload




NCLEX Review about Cardiac Nursing:
ANSWERS AND RATIONALE

46) C
- assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options A, B and D identify signs noted in deficient fluid volume.

47) C
- hyperactive bowel sounds indicate hyponatremia. Options A, B and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urinEdit Postse would be noted. Dry skin occurs in deficient fluid volume.

48) C
- troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins T are released to the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction.

49) B
- the normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.

50) D
- circulatory (fluid overload) is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure would also increase. Hematoma is characterized by ecchymosis, swelling and leakage at the IV insertion site, and hard and painful lumps at the site. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backaches, and tachycardia. Signs of electrolyte imbalance depend on the specific electrolyte.



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