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NCLEX Week 2 Questions,100% CORRECT

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The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first: A. Assess... for changes in vital signs. B. Draw an arterial blood gas. C. Evaluate heart sounds with the client leaning forward. D. Obtain a 12 Lead electrocardiogram. 2. A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply. A. Reduces myocardial oxygen consumption. B. Promotes reduction in respiratory rate. C. Prevents ventricular remodeling. D. Reduces blood pressure and heart rate. E. Reduces anxiety and fear. 3. A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? Round your answer to a whole number. 4. An older client has chest pain and shortness of breath. The health care provider (HCP) prescribes nitroglycerin tablets. What should the nurse instruct the client to do? A. Put the tablet under the tongue until it is absorbed. B. Swallow the tablet with 120 mL of water. C. Chew the tablet until it is dissolved. D. Place the tablet between his cheek and gums. 5.The Nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? A. BP 110/62 mm Hg, atrial fibrillation with HR 82, bibasilar crackles. B. Confusion, urine output 15 mL over the last 2 hours, orthopnea. C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1 edema of lower extremities. D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise. 6. The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: A. Administer atropine 0.5mg IV push. B. Auscultate for abnormal heart sounds. C. Prepare for transcutaneous pacing. D. Take the client’s blood pressure. 7.When preparing a client for cardiac angiogram, what actions should the nurse take? Select all that apply. A. Determine if the client has an allergy to liquid contrast material. B. Inform the client that an intravenous infusion will be started before the procedure. C. Remind the client to have nothing to eat or drink 8 hours before the procedure. D. Instruct the client to remain still during the procedure. E. Explain that the client will receive a fast-acting anesthetic. 8. A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: A. Heart rate irregular with S3. B. Heart rate irregular with S4. C. Heart rate irregular with aortic regurgitation. D. Heart rate irregular with mitral stenosis. 9. A 60-year old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should first: A. Administer the morphine. B. Obtain a 12-lead ECG. C. Obtain the blood work. D. Prescribe the chest radiograph. 10. An older adult has an MI 4 days ago. At 0930 the client’s B/P is 102/64 mm HG. After reviewing the clients progress notes the nurse should: Date Time 1/10 0030 Urinary Output the last 4hrs 90ml Cap Refill >3seconds BP 128/82 Extremities cool A. Give a fluid challenge/bolus B. Notify the HCP C. Assist the client with walking D. Administer furosemide as prescribed 11. When administering a thrombolytic drug to the client who is experiencing a MI and who has PVC’s, the expected outcome of the drug is to: A. Promote hydration B. Dissolve clots C. Prevent kidney failure D. Treat dysrhythmias. 12. The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor. The nurse should: A. Notify the HCP B. Call the rapid response team. C. Assess the client for changes in the rhythm. D. Administer lidocaine as prescribed. 13. The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving IV heparin sodium at 1,000 units per hour. During the second post procedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. The nurse should first: A. Don gloves and apply direct pressure over the site. B. Observe and document the bleeding. C. Notify the HCP D. Prepare protamine sulfate for IV administration. 14. A client admitted for myocardial infarction develops cardiogenic shock. An arterial line is inserted. Which prescription from the HCP should the nurse verify before implementing? A. Call for urine output <30 mL/h for 2 consecutive hours. B. Administer metoprolol 5mg IV push. C. Prepare for pulmonary artery catheter insertion. D. Titrate dobutamine to keep systolic BP>100mg Hg. 15. The nurse is monitoring a client admitted with a myocardial infarction who is at risk for cardiogenic shock. The nurse should report which changes noted from the client’s chart to the HCP? Nurses Progress Report 1300 1500 BP 110/70 100/65 Temp 98.7 (37.1) 99 (37.2) HR 70 75 RR 20 26 Output 90mL/hr 20mL/hr A. Urine output B. HR C. BP D. RR 16.The HCP prescribes continuous IV nitroglycerin infusion for the client with MI. The nurse should: A. Obtain an infusion pump for the medication. B. Take the BP every 4hrs. C. Monitor urine output hourly D. Obtain serum potassium levels daily. 17. The client is admitted to the telemetry unit due to chest pain. The client has poly substance abuse, and the nurse assess that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last. A. Obtain a history of which drug the client has used recently. B. Administer the prescribed dose of morphine. C. Position electrodes on the chest D. Take vitals. 18.A Client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies the following morning. Which statement should the nurse include in a teaching plan for this client? A. “You will continue to take your medications until the morning of the test.” B. “You might be sedated during the procedure and will not remember what has happened.” C. “This test is a noninvasive method of determining the effectiveness of your medication regimen.” D. “During the procedure, the HCP will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms.” 19. During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals: A. Two regular beats followed by one irregular beat. B. An irregular rhythm with a pulse rate >100. C. A pulse rate below 60bpm. D. A weak thready pulse. 20. When teaching a client about self-care following a placement of a new permanent pacemakerto the left upper chest, the nurse should include which information? Select all that apply A. Take and record daily pulse rate. B. Avoid air travel because of airport security alarms. C. Immobilize the affected arm for 4 to 6 weeks. D. Avoid using a microwave oven. E. Avoid lifting anything heavier than 3lbs (1.36kg). 21. A client has been admitted to the coronary care unit. The nurse observes a third-degree heart block at a rate of 35 bpm on the client’s cardiac monitor. The client has a blood pressure of 90/60 mmHg. The nurse should first: A. Prepare for transcutaneous pacing B. Prepare to defibrillate the client at 200 J C. Administer an IV lidocaine infusion D. Schedule the operating room for insertion of a permanent pacemaker 22. A client has atrial fibrillation and a heart rate of 165 bpm. In which order from first to last should the nurse implement these prescriptions? All options must be used. A. Administer oxygen via nasal cannula (ABCs) increasing the patient oxygen will decrease the demand for oxygen and thus allowing the heart rate to come down. B. Gather supplies for an IV insertion An IV is to be placed so that medications can be given to treat afib C. Place the client on a cardiac monitor (ECG) Monitor the client’s heart to show the afib and to see the rhythm D. Obtain vital signs including BP, P, R, T, and O2 saturation See how the patient responses to the oxygen and how the Afib is affecting them. 23. A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD). The spouse expresses anxiety about what would happen if the device discharges during physical contact. What should the nurse tell the spouse? A. Physical contact should be avoided whenever possible B. B.They will not feel the countershock C. C.The shock would feel like a “tingle”, but it would not cause any harm D. D.A warning device sounds before countershock, so there is time to move away 24. An older adult is admitted to the telemetry unit for the placement of a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after the insertion of a permanent pacemaker? a. Maintain skin integrity b. Maintain cardiac conduction stability c. Decrease cardiac output d. Increase activity level 25. The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The nurse knows that the client understands the discharge plan when the client: a. Selects a low-cholesterol diet to control coronary artery disease b. States a need for bed rest for 1 week after discharge c. Verbalizes safety precautions needed to prevent pacemaker malfunction. d. Explains the signs and symptoms of myocardial infarction (MI) 26. An 85-year-old client is admitted to the emergency department (ED) at 2000 hours with syncope, shortness of breath, and reported palpitations. At 2015, the nurse places the client on the ECG monitor and identifies the following rhythm. What should the nurse do? Select all the apply. a. Apply oxygen b. Prepare to defibrillate the client c. Monitor vital signs d. Have the client sign consent for cardioversion as prescribed e. Teach the client about warfarin treatment and the need for frequent blood testing f. Draw blood for a CBC count and thyroid function study 27. Upon assessment of third-degree heart block on the monitor, what should the nurse do first? A. Call a code. B. Begin cardiopulmonary resuscitation. C. Place transcutaneous pacing pads on the client. D. Prepare for defibrillation. 28. The nurse observes the cardiac rhythm for a client who is being admitted with a myocardial infarction. What should the nurse do first? A. Prepare for immediate cardioversion. B. Begin cardiopulmonary resuscitation (CPR). C. Check for a pulse. D. Prepare for immediate defibrillation. 29. A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital’s emergency department, where the admitting nurse quickly assesses the client’s condition. The most effective way to evaluate adequate oxygenation is to determine if: A. there is a pulse. B. pupils are reacting to light. C. mucous membranes are pink. D.systolic blood pressure is at least 80 mm Hg. 30. A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having a desired effect? A. The ventricular rate is increasing. B. The absent pulse is not palpable. C. The number of premature ventricular contractions is decreasing. D. The fine ventricular fibrillation changes to coarse ventricular fibrillation. 31. During cardiopulmonary resuscitation (CPR) for an adult, the rescuer’s hands should be placed two fingers’ width above the lower end of the sternum. Which organ would be most likely at risk for laceration by forceful compressions over the xiphoid process? A. Lung B. Liver C. Stomach D. Diaphragm 32. When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum: A. 0.5 Inches (1 cm) B. 1 Inch (2.5 cm) C. 1.5 inches (4 cm) D. 2 inches (5 cm) 33. If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first: A. Try using a bag mask device. B. Decrease the rate of compressions. C. Intubate the client. D. Reposition the airway. 34. During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by: A. Normal relaxation of the chest. B. Gentle pressure of the rescuer’s hand on the upper chest. C. The pressure of cardiac compressions. D. Turning the head to the side. 35. The rapid response team has been called to manage an unwitnessed cardiac arrest in a client’s hospital room. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is: A. 1 to 2 minutes B. 4 to 6 minutes C. 8 to 10 minutes D. 12 to 15 minutes 36. A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: A. Starts to become cyanotic. B. Cannot speak due to airway obstruction. C. Can make only minimal vocal noises. D. Is coughing vigorously. 37. When Preforming the Heimlich maneuver on a conscious adult victim the rescuer delivers inward and upward thrusts specifically: A. Above the umbilicus B. At the level of the xiphoid process. C. Over the victims midabdominal area D. Below the xiphoid process and above the umbilicus. . 38. The Monitor Technician informs the RN that the client started having premature ventricular contractions every other beat. What should the nurse do first? A. Activate the rapid response team B. Assess the client’s orientation and vitals’ signs. C. Call the HCP 39. A client returns to the nursing unit following successful synchronized cardioversion using transthoracic chest wall patches. The nurse should assess which when the client returns to room? Select all that apply. A. Vitals B. Skin of chest wall C. Arterial puncture site D. LOC E. Cardiac rhythm 40. The nurse is preparing to defibrillate a client on a cardiac monitor who is in VFIB. What should the nurse do? A. Move the paddle in the nurse’s left hand to the middle. B. Move the paddle on the nurse’s right hand to above the client’s nipple. C. Grasp the handles of the paddles to allow visibility of the black markings on the paddle. D. After pressing charge button and “calling allclear,” push the shock button. 41.41/128.The nurse is caring for a client who has become unresponsive. The BP is 80/40 mmHg and SpO2 is 90% on 50% face mask. The nurse should: A.Begin chest compressions B.Call the rapid response team C.Remove the family from the room D.Ventilate the client with a BVM. 42. A nurse working the day shift on a cardiac unit receives the following shift report: • Client 1: Admitted yesterday with hypokalemia. Awaiting repeat electrolyte lab results drawn at 0600. • Client 2: Experienced chest pain at 0630. Pain resolved after 2 sublingual nitroglycerin tablets. • Client 3: Scheduled for oral antihypertensive medications at 0900. Incontinent of urine during the night. • Client 4: Scheduled for coronary artery bypass surgery at 0800. The client’s family is in the client’s room. . 43. Which activity would be appropriate to delegate to the UAP for a client diagnosed with a myocardial infarction who is stable? A. Evaluate the lung sounds B. Help the client identify risk factors for CAD C. Provide teaching on a 2G sodium diet D. Record the intake and output. 44. The unlicensed assistive personnel reports to the nurse that a client is feeling short of breath. The clients BP is 124/78 mmHg 2 hours ago with a HR of 82. The unlicensed assistive personnel reports that the blood pressure is now 84/44 mmHg with a HR of 54. The client stated “I just do not feel good.” What actions should the nurse take? Select all that apply: A. Confirm the vital signs and complete a quick assessment. B. Inform the charge nurse of the change in condition and initiate the rapid response team. C. Make a quick check on other assigned clients before spending the amount of time required to take care of this client. D. Position the client in semi-Fowlers position. E. Stay with the client, and reassure the client. F. Call the HCP and report the situation using the SBAR format. 45. The nurse is assessing a client with heart failure whose blood pressure and weight are being monitored remotely. The nurse reviews the data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should first ask the client: A. How are you feeling today? B. Are you having shortness of breath? C. Did you calibrate the scales before using them? D. How much fluid did you drink during the last 24 hours? 46. The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which data are the best indicators that nursing interventions of monitoring and teaching have been effective? A. Ninety percent of clients have not gained weight B. Seventy-five percent of the clients viewed the educational DVD C. Eighty percent of the clients reported that they are taking the medications. D. Five percent of the clients required hospitalization in the last 90 days. 47. The nurse is planning care for a client who has just returned to the medical surgical unit following repair of an aortic aneurysm. The nurse should first assess the client for: A. Decreased urinary output B. Electrolyte imbalance C. Anxiety D. Wound infection 48. A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 1200 hours 2 days after the surgery, the client has abdominal distention. The nurse checks the progress notes in the clients medical record, as shown below:“7/7 2200 Note: The client is receiving D5W 1000 mL every 8H. The NG is attached to low suction and draining well. The client has been NPO except ice chips. The client has had 10mg morphine for pain at 0600.” What is most likely contributing to the client’s abdominal distention? A. Nasogastric tube B. Ice chips C. IV fluid intake D. Morphine 49. A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the HCP before having: A. Blood drawn B. An IV line inserted C. Major dental work D. An x-ray examination 50. The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hours ago. Which finding warrants further evaluation? A. Absent bowel sounds and mild abdominal distention. B. A BUN of 26 mg/dL (26 mmol/L) and creatinine of 1.2 mg/dL (1.2 umol/L) C. An arterial blood pressure of 80/50 mmHg D. 1 pedal pulses in bilateral lower extremities n [Show More]

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