Pediatric Cardiac Disorders NCLEX Questions
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Question 1 of 5.
The nurse who is beginning a shift on a cardiac step-down unit receives shift report for four clients. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients.
- A. The 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes
- B. The 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a “Do Not Resuscitate†order; whose family has just arrived
- C. The 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new-onset atrial fibrillation with rapid ventricular response
- D. The 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)
Correct arrangement
Explanation: The nurse should assess: C) Atrial fibrillation with rapid ventricular response is life-threatening; D) Elevated temperature and vital signs suggest infection; A) Heparin adjustment is pending but less urgent; B) End-stage cardiomyopathy with DNR is stable and family support is secondary.
Question 2 of 5.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of 'decreased cardiac output related to inability of the heart to pump effectively' is written. Which short-term goal would be best for the client?
A. The client will be able to ambulate in the hall by date of discharge.
B. The client will have an audible S1 and S2 with no S3 heard by end of shift.
C. The client will turn, cough, and deep breathe every two (2) hours.
D. The client will have a SaO2 reading of 98% by day two (2) of care.
Explanation: Absence of an S3 heart sound (B) indicates improved cardiac function, directly addressing decreased cardiac output. Ambulation (A) is long-term, turning/coughing (C) is an intervention, and SaO2 of 98% (D) is less specific to cardiac output.
Question 3 of 5.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?
A. The client's peripheral pitting edema has gone from 3+ to 4+.
B. The client is able to take the radial pulse accurately.
C. The client is able to perform ADLs without dyspnea.
D. The client has minimal jugular vein distention.
Explanation: Effective CHF treatment reduces fluid overload, allowing ADLs without dyspnea (C) and minimal JVD (D). Increased edema (A) indicates worsening, and pulse-taking (B) is a skill, not a treatment outcome.
Question 4 of 5.
The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?
A. The client diagnosed with myocardial infarction who has an audible S3 heart sound.
B. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema.
C. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
D. The client with chronic renal failure who has an elevated creatinine level.
Explanation: An S3 heart sound post-MI (A) indicates heart failure or fluid overload, requiring immediate assessment. Edema (B) is chronic, 94% SpO2 (C) is stable, and elevated creatinine (D) is expected in CRF.
Question 5 of 5.
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?
A. Check the client for peripheral edema and make sure the client takes a diuretic early in the day.
B. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.
C. Determine if the client has gained weight and instruct the client to keep the legs elevated.
D. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
Explanation: Leg cramps in CHF may indicate hypokalemia from diuretics. Monitoring potassium and assessing potassium-rich food intake (B) is appropriate. Edema/diuretic timing (A), weight/elevation (C), and ambulation/stretching (D) are less directly related.
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