NCLEX Review Questions Flashcards
Which instruction given to a patient who is about to undergo Holter monitoring is most appropriate?
A. “You may remove the monitor only to shower or bathe.”
B. “You should connect the monitor whenever you feel symptoms.”
C. “You should refrain from exercising while wearing this monitor.”
D. “You will need to keep a diary of all your activities and symptoms.”
D. “You will need to keep a diary of all your activities and symptoms.”
A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.
A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient (select all that apply)?
A. Assess for return of gag reflex.
B. Assess groin for hematoma or bleeding.
C. Monitor vital signs and oxygen saturation.
D. Position patient supine with head of bed flat.
E. Assess lower extremities for circulatory compromise.
A. Assess for return of gag reflex.
C. Monitor VS and O2 Sat
The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the patient to eat or drink. Vital signs and oxygen saturation are also important assessment parameters resulting from the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels. Therefore it is not necessary to monitor the patient’s groin and lower extremities in relation to this procedure or to maintain a flat position.
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy is most important for the nurse to assess before this procedure?
A. Iron
B. Iodine
C. Aspirin
D. Penicillin
B. Iodine
The physician will usually use an iodine-based contrast to perform this procedure. Therefore it is imperative to know whether or not the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.
The blood pressure of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding?
A. Stenosis of the heart valves
B. Decreased adrenergic sensitivity
C. Increased parasympathetic activity
D. Loss of elasticity in arterial vessels
D. Loss of elasticity in arterial vessels
An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.
The nurse is providing care for a patient who has decreased cardiac output related to heart failure. What should the nurse recognize about cardiac output?
A. Calculated by multiplying the patient’s stroke volume by the heart rate
B. The average amount of blood ejected during one complete cardiac cycle
C. Determined by measuring the electrical activity of the heart and the patient’s heart rate
D. The patient’s average resting heart rate multiplied by the patient’s mean arterial blood pressure
A. Calculated by multiplying the pt’s stroke volume by the heart rate
Cardiac output is determined by multiplying the patient’s stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.
Which effects of aging on the cardiovascular system should the nurse anticipate when providing care for older adults (select all that apply)?
A. Systolic murmur B. Diminished pedal pulses C. Increased maximal heart rate D. Decreased maximal heart rate E. Increased recovery time from activity
A. Systolic murmur
B. Diminished pedal pulses
D. Decreased maximal heart rate
E. Increased recovery time from activity
Well-documented cardiovascular effects of the aging process include valvular rigidity leading to systolic murmur, arterial stiffening leading to diminished pedal pulses or possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease rather than increase with age related to cellular aging and fibrosis of the conduction system.
The nurse knows the ventricular contractions are directly stimulated by which anatomic feature of the heart?
A. 1
B. 2
C. 3
D. 4
D. Purkinje fibers
The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.
When looking at the electrocardiogram (ECG) of the patient, the nurse knows that the QRS complex recorded on the ECG represents which part of the heart’s beat?
A. Depolarization of the atria
B. Repolarization of the ventricles
C. Depolarization from AV node throughout ventricles
D. The length of time it takes for the impulse to travel from the atria to the ventricles
C. Depolarization from AV node throughout ventricles
The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.
In palpating the patient’s pedal pulses, the nurse determines the pulses are absent. What factor could contribute to this result?
A. Atherosclerosis
B. Hyperthyroidism
C. Arteriovenous fistula
D. Cardiac dysrhythmias
A. Atherosclerosis
Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.
On return from surgery, the patient is wearing intermittent sequential compression stockings that he does not want to keep on. How should the nurse explain their necessity to the patient while he is on bed rest?
A. The socks keep the legs warm while the patient is not moving much.
B. The socks maintain the blood flow to the legs while the patient is on bed rest.
C. The socks keep the blood pressure down while the patient is stressed after surgery.
D. The socks provide compression of the veins to keep the blood moving back to the heart.
D. The socks provide compression of the veins to keep the blood moving back to the heart.
Intermittent sequential compression stockings provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.
The patient is confused about how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. The nurse can help the patient understand this with which explanation?
A. “The one vessel curves around from the left side to the right ventricle.”
B. “The LAD supplies blood to the left side of the heart and part of the right ventricle.”
C. “The right ventricle is supplied during systole primarily by the right coronary artery.”
D. “It is actually on your right side of the heart, but we call it the left anterior descending vessel.”
B. “The LAD supplies blood to the left side of the heart and part of the right ventricle.”
The best response is explaining that the lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole.
While auscultating the patient’s heart sounds with the bell of the stethoscope, the nurse hears these sounds. How should the nurse document what is heard?
A. Diastolic murmur
B. Third heart sound (S3)
C. Fourth heart sound (S4)
D. Normal heart sounds (S1, S2)
B. Third heart sound (S3)
The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.
A 59-year-old man has presented to the emergency department with chest pain. What component of his subsequent blood work is most clearly indicative of a myocardial infarction (MI)?
A. CK-MB
B. Troponin
C. Myoglobin
D. C-reactive protein
B. Troponin
Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.
While assessing the cardiovascular status of a patient, the nurse performs auscultation. Which intervention should the nurse implement in the assessment during auscultation?
A. Position the patient supine.
B. Ask the patient to hold his or her breath.
C. Palpate the radial pulse while auscultating the apical pulse.
D. Use the bell of the stethoscope when auscultating S1 and S2.
C. Palpate the radial pulse while auscultating the apical pulse.
In order to detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the patient to hold his or her breath during cardiac auscultation.
Auscultation of a patient’s heart reveals the presence of a murmur. What is this assessment finding a result of?
A. Increased viscosity of the patient’s blood
B. Turbulent blood flow across a heart valve
C. Friction between the heart and the myocardium
D. A deficit in heart conductivity that impairs normal contractility
B. Turbulent blood flow across a heart valve
Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.
