Basic Adult Health Care NCLEX Heart Questions
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Question 1 of 5.
A 52-year-old client with lung cancer tells the nurse that he has a low-grade fever (100.6°F [38.1°C]), nonproductive cough, and increasing fatigue. He completed the radiation therapy to the mass in his right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. What is the most appropriate response by the nurse?
A. Advise the client to take two acetaminophen tablets every 4 to 6 hours for 2 days and call back if his temperature increases to 101°F (38.3°C) or greater.
B. Advise the client that this is an expected side effect of the radiation therapy and to keep his appointment in 2 weeks.
C. Advise the client to come to the office to be examined today.
D. Advise the client to go to the nearest emergency department.
Explanation: Fever, cough, and fatigue post-radiation may indicate infection or pneumonitis, requiring prompt evaluation, especially in a lung cancer patient, so an office visit today is appropriate.
Question 2 of 5.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders should the nurse question?
A. Call for urine output <30 mL/hour for 2 consecutive hours.
B. Metoprolol (Lopressor) 5 mg I.V. push.
C. Symptom for a pulmonary artery catheter insertion.
D. Titrate Dobutamine (Dobutrex) to keep systolic BP >100.
Explanation: Metoprolol, a beta-blocker, can worsen cardiogenic shock by reducing heart rate and contractility. Other orders are appropriate for monitoring and supporting perfusion in cardiogenic shock.
Question 3 of 5.
When monitoring a client who is receiving t-PA, the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
A. Cardiac arrhythmias.
B. Hypertension.
C. Seizure.
D. Hypothermia.
Explanation: Reperfusion from t-PA can cause arrhythmias due to myocardial irritability as blood flow is restored, necessitating resuscitation equipment.
Question 4 of 5.
Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?
A. Take one tablet every 2 to 5 minutes until the pain stops.
B. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes.
C. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets.
D. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.
Explanation: Standard protocol for sublingual nitroglycerin is one tablet every 5 minutes for up to three doses. If pain persists, the client should seek medical help.
Question 5 of 5.
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
A. 1
B. 2
C. 3
D. 4
E. 5
Explanation: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb's point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.