Heart Failure NCLEX Questions 71-75

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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

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.


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Cardiac Nurse Education (66-70)

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66. The nurse is preparing to initiate an intravenous nitroglycerin drip on a client with acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside?

a) defibrillator
b) pulse oximeter
c) central venous pressure (CVP) tray
d) noninvasive blood pressure monitor

67. A client is in ventricular tachycardia and the physician orders intravenous (IV) lidocaine (xylocaine). The nurse plans to dilute the concentrated solution of lidocaine with:

a) lactated ringer's
b) normal saline 0.9%
c) 5% dextrose in water
d) normal saline 0.45%

68. A client who recently experienced a myocardial infarction is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). The nurse plans to teach the client that, during this procedure, a balloon-tipped catheter will:

a) inflate a meshlike device that will spring open
b) be used to compress the plaque against the coronary blood vessel wall
c) cut away the plaque from the coronary vessel wall using a cutting blade
d) be positioned in coronary artery to take pressure measurements in the vessel

69. A nurse is planning care for the client with heart failure. The nurse asks the dietary department to remove which item from all meal trays before delivering them to the client?

a) 1% milk
b) margarine
c) salt packets
d) decaffeinated tea


70. A client has just been admitted to the emergency department with chest pain. Serum enzyme levels are drawn, and the results indicate an elevated serum creatinine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with:

a) stable angina
b) unstable angina
c) prinzmetal's angina
d) new-onset myocardial infarction (MI)







Cardiac Nurse Education
Answers and Rationale

66) D

- Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.

67) C

- Lidocaine for IV administration is dispensed in concentrated and dilute formulations. The concentrated formulation must be diluted with 5% dextrose in water.

68) B

- In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option C describes coronary atherectomy, option A describes placement of a coronary stent, and option D describes part of the process used in cardiac catheterization.

69) C

- Sodium restriction reduces water retention and improves cardiac efficiency. A standard dietary modification for the client with heart failure is sodium restriction.

70) D

- Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise 3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Therefore, the client's results are compatible with new-onset MI. Options A, B, and C all refer to angina. These levels would not be elevated in angina.



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Cardiac Nurse Education (61-65)

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61. The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The appropriate nursing action is to:

a) prepare for defibrillation
b) continue to monitor the rhythm
c) notify the physician immediately
d) prepare to administer lidocaine hydrochloride (xylocaine)

62. The nurse is caring for a client who has been transferred to the surgical unit after having a pelvic exenteration. During the postoperative period, the client complains of pain in the calf area. What action should the nurse take?

a) ask the client to walk and observe the gait
b) lightly massage the calf area to relieve the pain
c) check the calf area for temperature, color, and size
d) administer prn morphine as prescribed for postoperative pain

63. A client has developed atrial fibrillation and has a ventricular rate of 150 bpm. The nurse assesses the client for:

a) flat neck veins
b) nausea and vomiting
c) hypotension and dizziness
d) hypertension and headache

64. A 45 year old client is admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia noted on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client?

a) you will continue to take your medications until the morning of the test
b) you will be sedated during the procedure and will not remember what has happened
c) this test is a noninvasive method of determining the effectiveness of your medication
d) during the procedure, a special wire is used to increase the heart rate and produce the irregular beats that caused your signs and symptoms

65. A nurse is providing diet teaching to a client with congestive heart failure (CHF). The nurse tells the client to avoid which of the following?

a) sherbet
b) steak sauce
c) apple juice
d) leafy green vegetables






Cardiac Nurse Education
Answers and Rationale

61) B

- As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the physician needs to be notified.

62) C

- The nurse monitors for postoperative complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options A and B could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client complaint is not the appropriate nursing action. Further assessment needs to take place.

63) C

- The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

64) D

- The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmias without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.

65) B

- Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with CHF should monitor sodium intake.


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Musculoskeletal NCLEX Questions (76-80)

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76. The nurse is assessing the client who has just been measured and fitted for crutches. The nurse determines that the client's crutches are fitted correctly if:

a) the top of the crutch is even with the axilla
b) the elbow is straight when the hands is on the handgrip
c) the client's axilla is resting on the crutch pad during ambulation
d) the elbow is at a 30-degree angle when the hand is on the handgrip

77. The nurse is assigned to care for a client who is in traction. The nurse ensures a safe environment for the client by:

a) making sure that the knots are at the pulleys
b) checking the weights to be sure that they are off the floor
c) making sure that the head of the bed is kept at a 90-degree angle
d) monitor the weights to be sure that they are resting on a firm surface

78. Musculoskeletal NCLEX Questions  about a client with a possible rib fracture who has never had a chest x-ray. The nurse plans to tell the client which of the following about the procedure?

a) the x-ray stimulates a small amount of pain
b) the client will be asked to breathe in and out continuously during the x-ray
c) the x-ray technologist will stand next to the client during the x-ray
d) it is necessary to remove jewelry and any other metal objects from the chest area

79. The nurse has an order to get the client out of bed to a chair on the first postoperative day following total knee replacement. The nurse plans to do which of the following to protect the knee joint?

a) apply a compression dressing and put ice on the knee while sitting
b) obtain a walker to minimize weigh-bearing by the client on the affected leg
c) lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine
d) apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting

80. The nurse is conducting a health screening clinic for osteoporosis. The nurse determines that which client seen in the clinic is at the greatest risk of developing this disorder?

a) a 25-year old female who jogs
b) a 36-year old male who has asthma
c) a 70-year old male who consumes excess alcohol
d) a sedentary 65-year old female who smokes cigarettes





Musculoskeletal NCLEX Questions
Answers and Rationale

76) D

- For optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three finger widths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla.

77) B

- To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

78) D

- Musculoskeletal NCLEX Questions Rationale - An x-ray is a photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. Any radiopaque objects such as jewelry or other metal must be removed from the chest area because they will interfere with the interpretation of the results. The x-ray is painless, and any discomfort would arise from repositioning a painful part for filming. The nurse may premedicate a client, if prescribed, who is at risk for pain. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize the risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the reproductive organs.

79) D

- The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The surgeon orders the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. Ice is not used unless prescribed. A compression dressing should already be in place on the wound. A CPM machine is used only while the client is in bed.

80) D

- Risk factors for osteoporosis include being female, postmenopausal status, advanced age, low-calcium diet, excessive alcohol intake, sedentary lifestyle, and cigarette smoking. The long-term use of corticosteroids, anticonvulsants, and furosemide (Lasix) also increase the risk.


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Musculoskeletal NCLEX Questions (1-8)

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Musculoskeletal NCLEX Questions (71-75)

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71. A client has sustained a closed fracture and has just has a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which has provided very little pain relief. The nurse interprets that this pain may be caused by:

a) infection under the cast
b) the anxiety of the client
c) impaired tissue perfusion
d) the newness of the fracture

72. The client with a fractured femur experiences sudden dyspnea. A set of arterial blood gases reveal the following: pH is 7.32, PaCO2 is 43, PaO2 is 58, and HCO3 is 20. Which of the following components of the ABG results supports the nurse's suspicion of fat embolus?

a) pH
b) PaO2
c) HCO3
d) PaCO2

73. The rehabilitation nurse is providing home care instruction for a client being discharged after above-the-knee amputation of the right lower limb with a fitted prosthesis. The nurse determines the client requires further teaching if the client makes which of the following statements?

a) I will elevate the residual limb on a pillow
b) I will change the residual limb sock everyday
c) I will check the residual limb for skin irritation daily
d) I will notify my prosthesis if my residual limb sock becomes stretched or ill-fitting

74. A client arrives at the clinic complaining of knee pain. On assessment the nurse notes that the knee area is swollen. The nurse interprets that the client's signs and symptoms likely indicate:

a) osteoporosis
b) a recent injury
c) rheumatoid arthritis
d) degenerative joint disease

75. A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other leg. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a:

a) strain
b) sprain
c) fracture
d) contusion






Musculoskeletal NCLEX Questions
Answers and Rationale

71) C

- Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved from these measures should be reported to the physician, because it may be caused by impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.

72) B

- A key feature of fat embolism is a significant degree of hypoxemia with a Pao2 often less than 60 mm Hg. Other features that distinguish fat embolism from pulmonary embolism are an elevated temperature and the presence of fat in the blood with fat embolus.

73) A

- Clients must avoid elevation of the residual limb to prevent flexion contractures of the right hip. Additionally, sitting in a chair should be limited to 1-hour intervals to avoid the same. If there is no contraindication, clients should lie in the prone position three to four times a day to promote hip extension. Limb socks should be removed daily, laundered in mild soap, and replaced with a clean sock. When the sock is removed, the residual limb should be inspected for erythema and excoriation. As the edema resolves, the residual limb shrinks and the sock may not fit properly, leading to skin irritation. The prosthetist should be notified of the ill-fitting sock.

74) B

- Pain and swelling are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative joint disease, osteoporosis, and rheumatoid arthritis may be accompanied by pain, but swelling may or may not be present.

75) C

- Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.



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NCLEX RN Questions: Musculoskeletal Injuries (66-70)

Welcome to NCLEX RN Questions about Musculoskeletal Injuries. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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66. A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type of wound care to the fasciotomy site?

a) dry sterile dressings
b) hydrocolloid dressings
c) wet sterile saline dressings
d) one-half strength betadine dressings

67. An older client admitted to the hospital with a hip fracture is placed in Buck's extension traction. The nurse plans to frequently monitor which specimen item?

a) temperature
b) mental state
c) neurovascular status
d) range of motion ability

68. Buck's extension traction is applied to an older client following a hip fracture. The nurse explains to the client that this type of traction is:

a) traction involving the use of a cast
b) skeletal traction involving the use of surgically inserted pins
c) circumferential traction involving the use of a belt around the body
d) skin traction involving the use of traction attached to the skin and soft tissues

69. A client has Buck's extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications from the device?

a) provide pin care once a shift
b) massage the skin of the right leg with lotion every 8 hours
c) inspect the skin on the right leg at least once every 8 hours
d) release the weights on the right leg for range of motion exercises daily

70. The nurse is caring for a client with a newly applied leg cast. The nurse prevents the development of compartment syndrome by:

a) elevating the limb and applying ice to the affected leg
b) elevating the limb and covering the limb with bath blankets
c) keeping the leg horizontal and applying ice to the affected leg
d) placing the leg in a slight dependent position and applying ice








NCLEX RN Questions:
Answers and Rationale

66) C

- The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require Betadine. Additionally, Betadine can be irritating to normal tissues.

67) C

- The neurovascular status of the extremity of the client in Buck's extension traction must be assessed frequently. Older clients are especially at risk for neurovascular compromise because many older clients already have disorders that affect the peripheral vascular system. Although the client's temperature is monitored, it is not specific to the use of Buck's extension traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck's extension traction is usually used preoperatively, which typically involves a few hours or 1 to 2 days, at the most. Range of motion of the involved leg is contraindicated in hip fractures.

68) D

- Buck's extension traction is a form of skin traction and involves the use of a belt or boot that is attached to the skin and soft tissues. The purpose of this type of traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (usually 5 to 10 pounds) to prevent injury to the skin. Options A, B, and C are incorrect descriptions.

69) C

Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.

70) A

- Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and the application of ice. The use of bath blankets or a dependent or horizontal leg position will not prevent this syndrome.



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NCLEX RN Questions: Musculoskeletal Injuries (61-65)

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61. A nurse is performing pin site care on a client in skeletal traction. Which finding would the nurse expect to note when assessing the pin sites?

a) loose pin sites
b) clear drainage from the pin sites
c) purulent drainage from the pin sites
d) redness and swelling around the pin sites

62. A nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur. The nurse prepares to perform a complete neurovascular assessment of the affected extremity and plans to assess:

a) vital signs and bilateral lung sounds
b) warmth of the skin and the temperature in the affected extremity
c) pain level and for the presence of edema in the affected extremity
d) color, sensation, movement, capillary refill, and pulse of the affected extremity

63. A client in the emergency department has a cast applied. The client arrives at the nursing unit, and the nurse prepares to transfer the client into the bed by:

a) placing ice on top of the cast
b) supporting the cast with the fingertips only
c) asking the client to support the cast during transfer
d) using the palms of the hands and soft pillows to support the cast

64. A nurse is caring for a client who has been placed in Buck's extension traction. The nurse provides for countertraction to reduce shear and friction by:

a) using a footboard
b) providing an overhead trapeze
c) slightly elevating the foot of the bed
d) slightly elevating the head of the bed

65. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that:

a) A bone fragment has injured the nerve supply in the area
b) an injured artery causes impaired arterial perfusion through the compartment
c) bleeding and swelling cause increased pressure in an area that cannot expand
d) the fascia expands with injury, causing pressure on underlying nerves and muscles






NCLEX RN Questions
Answers and Rationale

61) B

- A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and, if this is noted, the physician should be notified.

62) D

- A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.

63) D

- The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this action would be performed after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.

64) C

- The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. An overhead trapeze or footboard is not used to provide countertraction. Option C provides a force that opposes the traction force effectively without harming the client.

65) C

- Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.



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NCLEX RN Questions about Musculoskeletal Injuries (1-8)


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