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Nclex questions 4100 exam 3 Questions With Complete Solutions.
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Nclex questions 4100 exam 3 Questions With CompleteSolutions
A chaotic small, irregular, disorganized cardiac pattern suddenly
appears on a client's cardiac monitor. Which is the nurse's first
action?
1.Check the blood pressure.
2.Call the health care provider (HCP).
3.Check the client and the chest leads.
4.Initiate cardiopulmonary resuscitation (CPR). Correct Answer
3
Rationale:This type of pattern on the cardiac monitor indicates
either ventricular fibrillation or lead displacement. The first
action of the nurse is always to check the client and the chest
leads. If the client is nonresponsive and the leads are not the
problem, CPR would be the next choice, along with designating
another person to contact the HCP.
A chest x-ray report for a client indicates the presence of a left
apical pneumothorax. The nurse would assess the status of
breath sounds in that area by placing the stethoscope in which
location?
1.Just under the left clavicle
2.Midsternum, 1 inch to the left
3.Over the fifth intercostal space
4.Midsternum, 1 inch to the right Correct Answer 1
Rationale:The apex of the lung is the rounded, uppermost part of
the lung. Therefore, the nurse would place the stethoscope just
,under the left clavicle. All of the other options are incorrect
locations for assessing the left apex.
A client admitted to the hospital with coronary artery disease
complains of dyspnea at rest. The nurse caring for the client uses
which item as the best means to monitor respiratory status on an
ongoing basis?
1.Apnea monitor
2.Oxygen flowmeter
3.Telemetry cardiac monitor
4.Oxygen saturation monitor Correct Answer 4
Rationale:Dyspnea in the cardiac client often is accompanied by
hypoxemia. Hypoxemia can be detected by an oxygen saturation
monitor, especially if it is used continuously. An apnea monitor
detects apnea episodes, such as when the client has stopped
breathing briefly. An oxygen flowmeter is part of the setup for
delivering oxygen therapy. Cardiac monitors detect
dysrhythmias.
A client being admitted to the coronary care unit from the
emergency department has a stat prescription to receive a dose
of intravenous procainamide followed by a continuous infusion.
Based on this prescription, the nurse should assess for which
condition?
1.Dyspnea
2.Bradycardia
3.Hypertension
4.Ventricular ectopy Correct Answer 4
,Rationale:Procainamide is an antidysrhythmic medication used
to treat ventricular dysrhythmias unresponsive to lidocaine. The
other options are not indications for giving this medication.
A client develops atrial fibrillation with a ventricular rate of 140
beats/minute and signs of decreased cardiac output. Which
medication should the nurse anticipate administering first?
1.Warfarin
2.Lidocaine
3.Metoprolol
4.Atropine sulfate Correct Answer 3
Rationale:Beta blockers such as metoprolol slow conduction of
impulses through the atrioventricular node and decrease the
heart rate. In rapid atrial fibrillation, the goal first is to slow the
ventricular rate and improve the cardiac output and then attempt
to restore normal sinus rhythm. Atropine sulfate will further
increase the heart rate and will further decrease the cardiac
output. Although warfarin is administered to clients with atrial
fibrillation to prevent clots from forming in the atria, it will have
no effect in decreasing the ventricular rate or restoring normal
sinus rhythm. Lidocaine is useful only in suppressing ventricular
dysrhythmias.
A client has been treated for pleural effusion with a
thoracentesis. The nurse determines that this procedure has been
effective if the nurse notes which assessment finding?
1.Absence of dyspnea
2.Increased severity of cough
3.Dull percussion notes over lung tissue
, 4.Decreased tactile fremitus over lung tissue Correct Answer 1
Rationale:The client who has undergone thoracentesis should
experience relief of the signs and symptoms experienced before
the procedure. Typical signs and symptoms of pleural effusion
include dry, nonproductive cough; dyspnea (usually on
exertion); decreased or absent tactile fremitus; and dull or flat
percussion notes on respiratory assessment.
A client has developed uncontrolled atrial fibrillation with a
ventricular rate of 150 beats/min. What manifestation should the
nurse observe for when performing the client's focused
assessment?
1.Flat neck veins
2.Nausea and vomiting
3.Hypotension and dizziness
4.Clubbed fingertips and headache Correct Answer 3
Rationale:The client with uncontrolled atrial fibrillation with a
ventricular rate greater than 100 beats/min is at risk for low
cardiac output due to 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.
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
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