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Saunders Nclex Cardiovascular Latest Update 2024/2025
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Saunders Nclex Cardiovascular Latest Update 2024/2025
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Saunders NCLEX Cardiovascular1. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac
catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours
after the procedure?
1. Glipizide
2.
Metformin
3.
Repaglinide
4.
Regular insulin: Metformin
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the
injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin
in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do
not need to be withheld 24 hours before and 48 hours after cardiac catheterization.
2. 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 (16 mmol/L) and the serum creatinine leve
is 2.2 mg/dL (194 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: Acute kidney injury
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. 3. 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.
, Saunders NCLEX Cardiovascular
Check laboratory test results.
3.
Notify the health care provider. 4.
Continue to monitor for any rhythm change.: Continue to monitor for any rhythm change.
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.
4. 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.: Check the client's status and lead placement.
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.
5. 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: Status of airway
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.
6. 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
, Saunders NCLEX Cardiovascular
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: Activation
status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
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.
7. 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: Sinus tachycardia
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.
8. 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 peda
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.: The
neurovascular status is normal because of increased blood flow through the leg.
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.
9. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade
Which observation would indicate that the procedure was effective?
, Saunders NCLEX Cardiovascular
1.
Muffled heart sounds
2.
A rise in blood pressure
3.
Jugular venous distention
4.
Client expressions of dyspnea: A rise in blood pressure
Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or
distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs
with cardiac tamponade.
10. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement
by the client indicates the need for further teaching?
1.
"I should notify my doctor if my feet or legs start to swell." 2.
"My doctor told me to call his office if my pulse rate decreases below 60."
3.
"Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast."
4.
"My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."
"My spouse told me that since I have developed this problem, we are going to stop walking in the mall every
morning."
Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at
rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker
which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina
Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts
with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the health
care provider. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physica
exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with his
or her spouse.
11. The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding
indicates the presence of this complication?
1.
Flat neck veins
2.
A pulse rate of 60 beats/minute
3.
Muffled or distant heart sounds
4.
Wheezing on auscultation of the lungs: Muffled or distant heart sounds
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