Pediatric Cardiac Disorders NCLEX Questions Quizlet
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Question 1 of 5.
The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client's baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication?
A. BP 154/78 mm Hg
B. Pedal pulses palpable at +1
C. Left groin soft to palpation with 1 cm ecchymotic area
D. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm
Explanation: An apical pulse of 132 bpm with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. Slight BP elevation, +1 pulses, and minor ecchymosis are less concerning without additional context.
Question 2 of 5.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
C. Instruct the client to remove the saltshaker from the dinner table.
D. Encourage the client to monitor urine output for change in color to become dark.
E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Explanation: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
Question 3 of 5.
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
A. An elevated B-type natriuretic peptide (BNP).
B. An elevated creatine kinase (CK-MB).
C. A positive D-dimer.
D. A positive ventilation/perfusion (V/Q) scan.
Explanation: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
Question 4 of 5.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
A. Assist the client to go down to the smoking area for a cigarette.
B. Transport the client to the intensive care unit (ICU) via a stretcher.
C. Provide the client going home discharge-teaching instructions.
D. Help position the client who is having a portable x-ray done.
Explanation: Positioning for an x-ray (D) is within the UAP's scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
Question 5 of 5.
The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
A. Measure intake and output.
B. Provide two (2)g sodium diet.
C. Weigh the client daily.
D. Plan for frequent rest periods.
Explanation: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
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