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Complete NCLEX Study Materials
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71. The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. The nurse should use which of the following methods to cover the dressing?
a) apply a kerlix roll and tape it to the skin
b) apply a large, soft pad, and tape it to the skin
c) apply small Montgomery straps and tie the edges together
d) apply a Kling roll and tape the edge of the roll onto the bandage
72. A client develops bilateral wheezes, crackles from bases to apices, orthopnea, and tachypnea, and the nurse notes the presence of +2 pitting edema. The nurse suspects pulmonary edema and notifies the physician. While awaiting the physician's arrival, the nurse avoids which action?
a) elevating the client's legs
b) preparing to administer IV morphine sulfate
c) preparing to administer IV furosemide (Lasix)
d) placing the client in the high Fowler's position
73. Heart Failure NCLEX Questions about the nurse who is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that the:
a) procedure is performed in the operating room
b) initial catheter insertion is quite painful; after that, there is little or no pain
c) client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard x-ray table for about 4 hours
d) client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations
74. A nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). The nurse plans to do which of the following in delivering care to this client?
a) begin thrombolytic therapy
b) place the client on continuous cardiac monitoring
c) infuse intravenous (IV) fluid at a rate of 150 ml per hour
d) administer oxygen at a rate of 6 liters per minute by nasal cannula
75. The nurse is analyzing an ECG rhythm strip on an assigned client. The nurse notes that there are three small boxes from the beginning of the "P" wave to the "R" wave. The nurse records that the client's PR interval is:
a) 0.12 second
b) 0.20 second
c) 0.24 second
d) 0.40 second
Heart Failure NCLEX Questions
Answers and Rationale
After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:
Heart Failure NCLEX Questions 1-5
Complete NCLEX Study Materials
71. The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. The nurse should use which of the following methods to cover the dressing?
a) apply a kerlix roll and tape it to the skin
b) apply a large, soft pad, and tape it to the skin
c) apply small Montgomery straps and tie the edges together
d) apply a Kling roll and tape the edge of the roll onto the bandage
72. A client develops bilateral wheezes, crackles from bases to apices, orthopnea, and tachypnea, and the nurse notes the presence of +2 pitting edema. The nurse suspects pulmonary edema and notifies the physician. While awaiting the physician's arrival, the nurse avoids which action?
a) elevating the client's legs
b) preparing to administer IV morphine sulfate
c) preparing to administer IV furosemide (Lasix)
d) placing the client in the high Fowler's position
73. Heart Failure NCLEX Questions about the nurse who is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that the:
a) procedure is performed in the operating room
b) initial catheter insertion is quite painful; after that, there is little or no pain
c) client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard x-ray table for about 4 hours
d) client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations
74. A nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). The nurse plans to do which of the following in delivering care to this client?
a) begin thrombolytic therapy
b) place the client on continuous cardiac monitoring
c) infuse intravenous (IV) fluid at a rate of 150 ml per hour
d) administer oxygen at a rate of 6 liters per minute by nasal cannula
75. The nurse is analyzing an ECG rhythm strip on an assigned client. The nurse notes that there are three small boxes from the beginning of the "P" wave to the "R" wave. The nurse records that the client's PR interval is:
a) 0.12 second
b) 0.20 second
c) 0.24 second
d) 0.40 second
Heart Failure NCLEX Questions
Answers and Rationale
71) D
- With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps could not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway). Standard dressing technique includes the use of Kling rolls on circumferential dressings.
72) A
- Elevating the client's legs would rapidly increase venous return to the right side of the heart and worsen the client's condition. The feet should be in the horizontal position, or the client could dangle at the bedside if the client's condition permits. Anxiety causes an increase in the oxygen demands on the heart. Morphine sulfate reduces anxiety and causes peripheral vasodilation and is likely to be prescribed. Furosemide will be prescribed because of its diuretic action. A high Fowler's position increases the thoracic capacity, allowing for improved ventilation.
73) D
- Heart Failure NCLEX Questions Rationale: Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so there is little to no pain with catheter insertion. The X-ray table is hard and may be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.
74) B
- Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring, administering oxygen at a rate of 2 to 4 liters per minute unless otherwise ordered, and ensuring an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep vein open rate to prevent fluid overload and heart failure. Thrombolytic therapy may or may not be prescribed by the physician. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event.
75) A
- Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:
Heart Failure NCLEX Questions 1-5
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