NCLEX 4100 Exam 3: Cardiac Catheterization Qs with Answers and Rationales, Exams of Nursing

Download NCLEX 4100 Exam 3: Cardiac Catheterization Qs with Answers and Rationales and more Exams Nursing in PDF only on Docsity!

NCLEX 4100 Exam 3 Questions With

100% Correct Answers 2024

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure?

1. Bed rest in high Fowler's position
2. Bed rest with bathroom privileges only 3.Bed rest with head elevation at 60 degrees
3. Bed rest with head elevation no greater than 30 degrees - Correct Answer- Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

1. Excessive bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
4. 50 mL of drainage in the drainage collection chamber
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation - Correct Answer-3, 4, 5, 6 Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and

exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

1. Stay very still.
2. Exhale very quickly.
3. Inhale and exhale quickly.
4. Perform the Valsalva maneuver. - Correct Answer- Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale,

and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

1. Do nothing, because this is an expected finding.
2. Check for an air leak, because the bubbling should be intermittent.
3. Increase the suction pressure so that the bubbling becomes vigorous.
4. Clamp the chest tube and notify the health care provider immediately. - Correct Answer- Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and

as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.

1. Facial edema in the morning 2.Weight loss of 20 lb (9 kg) in 1 month
2. Serum calcium level of 12 mg/dL (3.0 mmol/L)
3. Serum sodium level of 136 mg/dL (136 mmol/L)

5. Serum potassium level of 3.4 mg/dL (3.4 mmol/L)
6. Numbness and tingling of the lower extremities - Correct Answer-1, 3, 6 Rationale: Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL (136 mmol/L) is a normal level. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
7. Slow, deep respirations
8. Rapid, deep respirations

3. Paradoxical respirations
4. Pain, especially with inspiration - Correct Answer- Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
5. Cyanosis 2.Hypotension
6. Paradoxical chest movement
7. Dyspnea, especially on exhalation - Correct Answer-

Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate - Correct Answer- The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is

followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken - Correct Answer- The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

1. Administer digoxin.
2. Defibrillate the client.
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing - Correct Answer-4. Prepare for transcutaneous pacing. Rationale: Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply.

1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position - Correct Answer-1, 2, 3, 4 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's

position to ease the work of breathing. Furosemide, a rapid- acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. Test-Taking Strategy: Note the strategic words priority interventions and focus on the client's diagnosis. Recall the pathophysiology associated with pulmonary edema and use the ABCs—airway, breathing, and circulation—to help determine priority interventions. Review priority interventions for the client with pulmonary edema if you had difficulty with this question. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

1.Stridor 2.Crackles 3.Scattered rhonchi 4.Diminished breath sounds - Correct Answer- Rationale:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway. A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1.Bradycardia 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure - Correct Answer- Rationale:Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became

apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL ( mmol/L) and the serum creatinine level is 2.2 mg/dL ( mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1.Hypovolemia 2.Acute kidney injury 3.Glomerulonephritis 4.Urinary tract infection - Correct Answer- Rationale:The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL

(44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1.Check vital signs. 2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to monitor for any rhythm change. - Correct Answer- Rationale:Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1.Call a code. 2.Call the health care provider. 3.Check the client's status and lead placement. 4.Press the recorder button on the electrocardiogram console.

• Correct Answer- Rationale:Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment. The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?

1.Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions - Correct Answer- Rationale:Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0. seconds), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1.It can develop into ventricular fibrillation at any time. 2.It is almost impossible to convert to a normal rhythm. 3.It is uncomfortable for the client, giving a sense of impending doom. 4.It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. - Correct Answer- Rationale:Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and

myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1.Sensation of palpitations 2.Causative factors, such as caffeine 3.Blood pressure and oxygen saturation 4.Precipitating factors, such as infection - Correct Answer- Rationale:Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms? 1.Flat neck veins 2.Nausea and vomiting 3.Hypotension and dizziness 4.Hypertension and headache - Correct Answer- Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1.Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation

4.Ventricular tachycardia - Correct Answer- Rationale:Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation. The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1.Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4.Confirm that the rhythm is actually ventricular fibrillation. - Correct Answer- Rationale:Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying

rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation. The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1.Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2.Nonarousable, sinus rhythm, BP 88/60 mm Hg 3.Arousable, marked bradycardia, BP 86/54 mm Hg 4.Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg - Correct Answer-1 Rationale:After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?

1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness - Correct Answer-2 Rationale:Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1.Anxiety level of the client and family 2.Presence of a MedicAlert card for the client to carry 3.Knowledge of restrictions on postdischarge physical activity 4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver - Correct Answer-4 Rationale:The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know

whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm - Correct Answer-1 Rationale:Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal- width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after

undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1.The neurovascular status is normal because of increased blood flow through the leg. 2.The neurovascular status is moderately impaired, and the surgeon should be called. 3.The neurovascular status is slightly deteriorating and should be monitored for another hour. 4.The neurovascular status is adequate from an arterial approach, but venous complications are arising. - Correct Answer-1 Rationale:An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The

client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1.Check the urine specific gravity. 2.Call the health care provider (HCP). 3.Put the IV line on a pump so that the infusion rate is sure to stay stable. 4.Check to see if the client had a blood sample for a serum albumin level drawn. - Correct Answer-2 Rationale:Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6- 1.2 mg/dL (53-106 mcmol/L) and female, 0.5-1.1 mg/dL (44-97 mcmol/L). Options 1 and 4 are not associated with the data in the question. The IV should have already been on a pump. Urine output lower than 30 mL/hour is reported to the HCP. The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of