Exam (elaborations)
Saunders nclex cardiovascular Latest Update 2024
- Course
- Institution
Saunders nclex cardiovascular Latest Update 2024
[Show more]
Content preview
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 level 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
, Saunders NCLEX Cardiovascular
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.
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.
, Saunders NCLEX Cardiovascular
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
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
, Saunders NCLEX Cardiovascular
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 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.: The neurovascular status is normal because of increased blood flow through the leg.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller TESTCHIEF. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
75759 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now