Which of the following physical assessment findings are normal for a c

Basic Adult Health Care NCLEX Heart Questions

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Question 1 of 5.

Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?

A. Increased anteroposterior chest diameter.

B. Underdeveloped neck muscles.

C. Collapsed neck veins.

D. Increased chest excursions with respiration.

Explanation: Advanced COPD causes air trapping, increasing anteroposterior chest diameter (barrel chest). Neck muscles may hypertrophy from respiratory effort. Neck veins may distend, and chest excursions decrease due to lung hyperinflation.

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.