NCLEX Review about Cardiac Nursing 56-60

NCLEX Review about Cardiac Nursing


56. A nurse is caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse assesses the infant for which early sign of CHF?

a) cough
b) pallor
c) tachycardia
d) slow and shallow breathing

57. A physician has prescribed oxygen as needed for an infant with congestive heart failure (CHF). In which situation should the nurse administer the oxygen to the infant?

a) during sleep
b) when changing the infant's diapers
c) when the mother is holding the infant
d) when drawing blood for electrolyte testing



58. A nurse is monitoring an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and the need to call the physician?

a) bradypnea
b) diaphoresis
c) decreased blood pressure
d) a weight gain of 1 lb in 1 day

59. The nurse is preparing the client with chronic heart failure for discharge to home. Which statement if made by the client indicates the highest priority teaching need?

a) I will get out of bed slowly in the morning
b) I plan to rest as much as possible when I get home
c) I will let my health care provider know if I gain 4 pounds or more in two days
d) I will have to cut down on potato chips

60. A 22-year old adult has cholesterol blood test done at screening clinic sponsored by a local health club. The nurse volunteering at the screening teaches the client that diet and exercise should be used as health measures to keep the total cholesterol below:

a) 80 mg/dL
b) 200 mg/dL
c) 250 mg/dL
d) 300 mg/dL




NCLEX REVIEW ABOUT CARDIAC NURSING:
ANSWERS AND RATIONALE

56) C

- The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign.

57) D

Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options A,B, C are not likely to produce crying in the infant.

58) D

A weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the physician. Tachypnea and an increased blood pressure would occur with fluid accumulation. Diaphoresis is a sign of CHF but is not specific to fluid accumulation, and usually occurs with exertional activities.

59) B

- the client with chronic heart failure should have a balance between rest and activity. Therefore, choice B indicates knowledge deficit of the client and this indicates need for further teaching.

60) B

- The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Options C and D are elevated values and place the client at risk for cardiovascular disease. Although option A is a low cholesterol level, option B identifies the realistic value to assist in preventing cardiovascular disease.


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NCLEX Review about Cardiac Nursing (1-5)


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NCLEX Review about Cardiac Nursing (61-65)