Basic Adult Health Care NCLEX Heart Questions
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Question 1 of 5.
A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive:
A. Hydromorphone (Dilaudid) I.V.
B. Diltiazem (Cardizem) PO.
C. Meperidine (Demerol) I.M.
D. Promethazine (Phenergan).
Explanation: Severe pain requires a potent analgesic. Hydromorphone I.V. (A) provides rapid, effective pain relief. Diltiazem (B) is for cardiac conditions, not pain. Meperidine (C) is less preferred due to side effects, and promethazine (D) is for nausea, not pain.
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.