PN NCLEX 6th EDITION – ADULT HEALTH/CARDIOVASCULAR
The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of
coronary artery disease (CAD). The client reveals having been under a great deal of stress
recently. Which should the nurse do next?
- Explore with the client the sources of stress in life.
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU)
to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring
for the client expects to note which type of activity prescribed?
- Bathroom privileges and self-care activities
Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal
coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the
nurse about its purpose. What is the purpose of the aspirin?
- To prevent the formation of clots
A client has just returned from the cardiac catheterization laboratory. The left femoral vessel
was used as the access site. After returning the client to bed, the nurse places a sign above the
bed stating that the client should remain on bed rest and in which position?
- With the head of the bed elevated no more than 15 degrees
A client is seen in the health care provider's office for a physical examination after experiencing
unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220
pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18
breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In
order to best collect relevant data, which question should the nurse ask the client first?
- "When was the last time you had your blood pressure checked?"
The nurse working in a long-term care facility is collecting data from a client experiencing chest
pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if
which observation is made by the nurse?
- The pain has not been unrelieved by rest and nitroglycerin tablets.
,The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the
emergency department with a diagnosis of coronary artery disease (CAD). The nurse should
place highest priority on making sure that which is available at the bedside?
- Oxygen tubing and flowmeter
The nurse is collecting data from a client with varicose veins. Which finding would the nurse
identify as an indication of a potential complication associated with this disorder?
- The client complains of leg edema, and skin breakdown has started.
A client is at risk for complications of heart failure. Which is the nurse's priority for early
detection of the most likely cause of complications with this client?
- Evaluating total body fluid
The nurse is caring for a client with left-sided heart failure. Which clinical signs are most
important for the nurse to communicate to the health care provider?
Select all that apply.
-Pink-tinged frothy sputum
-Increase in respiratory rate
-Auscultation of crackles throughout the lungs
The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse
determines that the client understands the instructions if the client states that which food item
will be avoided?
- Catsup
The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to
minimize its occurrence. Which statement by the client indicates an understanding of this
information?
- "I should avoid sitting in one position for long periods of time."
, The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce
recurrence of chest pain. The nurse should stress to the client the importance of taking which
measure?
- Avoiding exposure to either very hot or very cold weather
The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting
blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as
indicative of which finding?
- Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and
shortness of breath, and the client is visibly anxious. The nurse understands that a life-
threatening complication of this condition is which?
- Pulmonary embolism
The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is
probably unrelated to the AAA?
- Hyperactive bowel sounds in the area
The nurse is preparing to care for a client who will be arriving from the recovery room after an
above-the-knee amputation. The nurse ensures that which priority item is available for
emergency use?
- Surgical tourniquet
A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse
should become concerned with which fibrinogen level?
- 90 mg/dL
A client being seen in the emergency department for complaints of chest pain confides in the
nurse about regular use of cocaine as a recreational drug. The nurse takes which important
action in delivering holistic nursing care to this client?
The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of
coronary artery disease (CAD). The client reveals having been under a great deal of stress
recently. Which should the nurse do next?
- Explore with the client the sources of stress in life.
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU)
to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring
for the client expects to note which type of activity prescribed?
- Bathroom privileges and self-care activities
Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal
coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the
nurse about its purpose. What is the purpose of the aspirin?
- To prevent the formation of clots
A client has just returned from the cardiac catheterization laboratory. The left femoral vessel
was used as the access site. After returning the client to bed, the nurse places a sign above the
bed stating that the client should remain on bed rest and in which position?
- With the head of the bed elevated no more than 15 degrees
A client is seen in the health care provider's office for a physical examination after experiencing
unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220
pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18
breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In
order to best collect relevant data, which question should the nurse ask the client first?
- "When was the last time you had your blood pressure checked?"
The nurse working in a long-term care facility is collecting data from a client experiencing chest
pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if
which observation is made by the nurse?
- The pain has not been unrelieved by rest and nitroglycerin tablets.
,The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the
emergency department with a diagnosis of coronary artery disease (CAD). The nurse should
place highest priority on making sure that which is available at the bedside?
- Oxygen tubing and flowmeter
The nurse is collecting data from a client with varicose veins. Which finding would the nurse
identify as an indication of a potential complication associated with this disorder?
- The client complains of leg edema, and skin breakdown has started.
A client is at risk for complications of heart failure. Which is the nurse's priority for early
detection of the most likely cause of complications with this client?
- Evaluating total body fluid
The nurse is caring for a client with left-sided heart failure. Which clinical signs are most
important for the nurse to communicate to the health care provider?
Select all that apply.
-Pink-tinged frothy sputum
-Increase in respiratory rate
-Auscultation of crackles throughout the lungs
The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse
determines that the client understands the instructions if the client states that which food item
will be avoided?
- Catsup
The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to
minimize its occurrence. Which statement by the client indicates an understanding of this
information?
- "I should avoid sitting in one position for long periods of time."
, The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce
recurrence of chest pain. The nurse should stress to the client the importance of taking which
measure?
- Avoiding exposure to either very hot or very cold weather
The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting
blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as
indicative of which finding?
- Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and
shortness of breath, and the client is visibly anxious. The nurse understands that a life-
threatening complication of this condition is which?
- Pulmonary embolism
The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is
probably unrelated to the AAA?
- Hyperactive bowel sounds in the area
The nurse is preparing to care for a client who will be arriving from the recovery room after an
above-the-knee amputation. The nurse ensures that which priority item is available for
emergency use?
- Surgical tourniquet
A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse
should become concerned with which fibrinogen level?
- 90 mg/dL
A client being seen in the emergency department for complaints of chest pain confides in the
nurse about regular use of cocaine as a recreational drug. The nurse takes which important
action in delivering holistic nursing care to this client?
