Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
A client admitted to the hospital with
chest pain and a history of type 2 dia-
1.Glipizide
betes mellitus is scheduled for cardiac
2.Metformin*****
catheterization. Which medication would
3.Repaglinide
need to be withheld for 24 hours before
4.Regular insulin
the procedure and for 48 hours after the
procedure?
A client who had cardiac surgery 24
hours ago has had a urine output aver-
aging 20 mL/hour for 2 hours. The client
received a single bolus of 500 mL of in-
travenous fluid. Urine output for the sub- 1.Hypovolemia
sequent hour was 25 mL. Daily laborato- 2.Acute kidney injury*******
ry results indicate that the blood urea ni- 3.Glomerulonephritis
trogen level is 45 mg/dL (16 mmol/L) and 4.Urinary tract infection
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?
The nurse is reviewing an electrocardio-
gram rhythm strip. The P waves and QRS 1.Check vital signs.
complexes are regular. The PR interval is 2.Check laboratory test results.
0.16 seconds, and QRS complexes mea- 3.Notify the health care provider.
sure 0.06 seconds. The overall heart rate 4.Continue to monitor for any rhythm
is 64 beats/minute. Which action should change.********
the nurse take?
A client is wearing a continuous cardiac 1.Call a code.
monitor, which begins to sound its alarm. 2.Call the health care provider.
The nurse sees no electrocardiographic 3.Check the client's status and lead
complexes on the screen. Which is the placement.****** 4.Press the recorder
priority nursing action? button on the electrocardiogram console.
1.Blood pressure
The nurse is evaluating a client's re-
2.Status of airway*******
sponse to cardioversion. Which assess-
3.Oxygen flow rate
ment would be the priority?
4.Level of consciousness
1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the
, Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
The nurse is caring for a client who client to carry 3.Knowledge of restric-
has just had implantation of an automat- tions on postdischarge physical activity
ic internal cardioverter-defibrillator. The 4.Activation status of the device, heart
nurse should assess which item based rate cutoff, and number of shocks it is
on priority? programmed to deliver*******
A client's electrocardiogram strip shows
atrial and ventricular rates of 110
1.Sinus tachycardia******
beats/minute. The PR interval is 0.14
2.Sinus bradycardia
seconds, the QRS complex measures
3.Sinus dysrhythmia
0.08 seconds, and the PP and RR inter-
4.Normal sinus rhythm
vals are regular. How should the nurse
correctly interpret this rhythm?
1. The neurovascular status is normal
because of increased blood flow through
The nurse is assessing the neurovascu-
the leg.*******
lar status of a client who returned to the
2.The neurovascular status is moderate-
surgical nursing unit 4 hours ago after
ly impaired, and the surgeon should be
undergoing aortoiliac bypass graft. The
called.
affected leg is warm, and the nurse notes
3.The neurovascular status is slightly de-
redness and edema. The pedal pulse
teriorating and should be monitored for
is palpable and unchanged from admis-
another hour.
sion. How should the nurse correctly in-
4.The neurovascular status is adequate
terpret the client's neurovascular status?
from an arterial approach, but venous
complications are arising.
1.
Muffled heart sounds
The nurse is evaluating the condition of a
2.
client after pericardiocentesis performed
A rise in blood pressure******
to treat cardiac tamponade. Which ob-
3.
servation would indicate that the proce-
Jugular venous distention
dure was effective?
4.
Client expressions of dyspnea
1."I should notify my doctor if my feet or
legs start to swell."
A client with variant angina is sched-
2."My doctor told me to call his office if
uled to receive an oral calcium channel
my pulse rate decreases below 60."
blocker twice daily. Which statement by
3."Avoiding grapefruit juice will definitely
be a challenge for me, since I usually
, Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
drink it every morning with breakfast."
4."My spouse told me that since I have
the client indicates the need for further
developed this problem, we are going
teaching?
to stop walking in the mall every morn-
ing."*******
The nurse is monitoring a client with
1.Flat neck veins
acute pericarditis for signs of cardiac
2.A pulse rate of 60 beats/minute
tamponade. Which assessment finding
3.Muffled or distant heart sounds****
indicates the presence of this complica-
4.Wheezing on auscultation of the lungs
tion?
1."I need to be sure not to go barefoot
around the house."
The home care nurse is providing in-
2."If I cut my toenails, I need to be sure
structions to a client with an arterial is-
that I cut them straight across."
chemic leg ulcer about home care man-
3."It is all right to apply lanolin to my feet,
agement and self-care management.
but I shouldn't place it between my toes."
Which statement, if made by the client,
4."I need to be sure that I elevate my leg
indicates a need for further instruction?
above the level of my heart for at least an
hour every day."********
The nurse is providing instructions to a
1.Bananas
client with a diagnosis of hypertension
2.Broccoli
regarding high-sodium items to be avoid-
3.Antacids*******
ed. The nurse instructs the client to avoid
4.Cantaloupe
consuming which item?
1.Use nail polish to protect the nail beds
from injury. 2.Wear gloves for all activities
The nurse is preparing discharge in- involving the use of both hands.
structions for a client with Raynaud's dis- 3.Stop smoking because it causes cuta-
ease. The nurse should plan to provide neous blood vessel spasm. ********
which instruction to the client? 4.Always wear warm clothing, even in
warm climates, to prevent vasoconstric-
tion.
1.
The nurse is developing a plan of care for Keep the legs aligned with the heart.
a client with varicose veins in whom skin 2.
breakdown occurred over the varicosi- Elevate the legs higher than the
heart.*********
, Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
3.
Clean the skin with alcohol every hour.
ties as a result of secondary infection.
4.
Which is a priority intervention?
Position the client onto the side during
every shift.
The nurse in the medical unit is reviewing
the laboratory test results for a client who
has been transferred from the intensive 1.Heart failure
care unit (ICU). The nurse notes that a 2.Atrial fibrillation
cardiac troponin T assay was performed 3.Myocardial infarction********
while the client was in the ICU. The nurse 4.Ventricular tachycardia
determines that this test was performed
to assist in diagnosing which condition?
The nurse is caring for a client with car-
diac disease who has been placed on
1.Hypotension********
a cardiac monitor. The nurse notes that
2.Flat neck veins
the client has developed atrial fibrillation
3.Complaints of nausea
and has a rapid ventricular rate of 150
4.Complaints of headache
beats/minute. The nurse should next as-
sess the client for which finding?
The nurse is performing an assessment
1.Listening to lung sounds*******
on a client with a diagnosis of left-sided
2.Palpating for organomegaly
heart failure. Which assessment compo-
3.Assessing for jugular vein distention
nent would elicit specific information re-
4.Assessing for peripheral and sacral
garding the client's left-sided heart func-
edema
tion?
1."This is a normal finding." *********
The nurse is participating in a class on
2."This is indicative of atrial flutter."
rhythm strip interpretation. Which state-
3."This is indicative of atrial fibrillation."
ment by the nurse indicates an under-
4."This is indicative of impending rein-
standing of a PR interval of 0.20?
farction."
The nurse in the medical unit is assigned
1.Anxiety related to the need to make
to provide discharge teaching to a client
lifestyle changes 2.Boredom resulting
with a diagnosis of angina pectoris. The
from having already learned the material
nurse is discussing lifestyle changes that
3.An attempt to ignore or deny the need
are needed to minimize the effects of the
to make lifestyle changes*********
disease process. The client continually
Study online at https://quizlet.com/_di8no0
A client admitted to the hospital with
chest pain and a history of type 2 dia-
1.Glipizide
betes mellitus is scheduled for cardiac
2.Metformin*****
catheterization. Which medication would
3.Repaglinide
need to be withheld for 24 hours before
4.Regular insulin
the procedure and for 48 hours after the
procedure?
A client who had cardiac surgery 24
hours ago has had a urine output aver-
aging 20 mL/hour for 2 hours. The client
received a single bolus of 500 mL of in-
travenous fluid. Urine output for the sub- 1.Hypovolemia
sequent hour was 25 mL. Daily laborato- 2.Acute kidney injury*******
ry results indicate that the blood urea ni- 3.Glomerulonephritis
trogen level is 45 mg/dL (16 mmol/L) and 4.Urinary tract infection
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?
The nurse is reviewing an electrocardio-
gram rhythm strip. The P waves and QRS 1.Check vital signs.
complexes are regular. The PR interval is 2.Check laboratory test results.
0.16 seconds, and QRS complexes mea- 3.Notify the health care provider.
sure 0.06 seconds. The overall heart rate 4.Continue to monitor for any rhythm
is 64 beats/minute. Which action should change.********
the nurse take?
A client is wearing a continuous cardiac 1.Call a code.
monitor, which begins to sound its alarm. 2.Call the health care provider.
The nurse sees no electrocardiographic 3.Check the client's status and lead
complexes on the screen. Which is the placement.****** 4.Press the recorder
priority nursing action? button on the electrocardiogram console.
1.Blood pressure
The nurse is evaluating a client's re-
2.Status of airway*******
sponse to cardioversion. Which assess-
3.Oxygen flow rate
ment would be the priority?
4.Level of consciousness
1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the
, Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
The nurse is caring for a client who client to carry 3.Knowledge of restric-
has just had implantation of an automat- tions on postdischarge physical activity
ic internal cardioverter-defibrillator. The 4.Activation status of the device, heart
nurse should assess which item based rate cutoff, and number of shocks it is
on priority? programmed to deliver*******
A client's electrocardiogram strip shows
atrial and ventricular rates of 110
1.Sinus tachycardia******
beats/minute. The PR interval is 0.14
2.Sinus bradycardia
seconds, the QRS complex measures
3.Sinus dysrhythmia
0.08 seconds, and the PP and RR inter-
4.Normal sinus rhythm
vals are regular. How should the nurse
correctly interpret this rhythm?
1. The neurovascular status is normal
because of increased blood flow through
The nurse is assessing the neurovascu-
the leg.*******
lar status of a client who returned to the
2.The neurovascular status is moderate-
surgical nursing unit 4 hours ago after
ly impaired, and the surgeon should be
undergoing aortoiliac bypass graft. The
called.
affected leg is warm, and the nurse notes
3.The neurovascular status is slightly de-
redness and edema. The pedal pulse
teriorating and should be monitored for
is palpable and unchanged from admis-
another hour.
sion. How should the nurse correctly in-
4.The neurovascular status is adequate
terpret the client's neurovascular status?
from an arterial approach, but venous
complications are arising.
1.
Muffled heart sounds
The nurse is evaluating the condition of a
2.
client after pericardiocentesis performed
A rise in blood pressure******
to treat cardiac tamponade. Which ob-
3.
servation would indicate that the proce-
Jugular venous distention
dure was effective?
4.
Client expressions of dyspnea
1."I should notify my doctor if my feet or
legs start to swell."
A client with variant angina is sched-
2."My doctor told me to call his office if
uled to receive an oral calcium channel
my pulse rate decreases below 60."
blocker twice daily. Which statement by
3."Avoiding grapefruit juice will definitely
be a challenge for me, since I usually
, Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
drink it every morning with breakfast."
4."My spouse told me that since I have
the client indicates the need for further
developed this problem, we are going
teaching?
to stop walking in the mall every morn-
ing."*******
The nurse is monitoring a client with
1.Flat neck veins
acute pericarditis for signs of cardiac
2.A pulse rate of 60 beats/minute
tamponade. Which assessment finding
3.Muffled or distant heart sounds****
indicates the presence of this complica-
4.Wheezing on auscultation of the lungs
tion?
1."I need to be sure not to go barefoot
around the house."
The home care nurse is providing in-
2."If I cut my toenails, I need to be sure
structions to a client with an arterial is-
that I cut them straight across."
chemic leg ulcer about home care man-
3."It is all right to apply lanolin to my feet,
agement and self-care management.
but I shouldn't place it between my toes."
Which statement, if made by the client,
4."I need to be sure that I elevate my leg
indicates a need for further instruction?
above the level of my heart for at least an
hour every day."********
The nurse is providing instructions to a
1.Bananas
client with a diagnosis of hypertension
2.Broccoli
regarding high-sodium items to be avoid-
3.Antacids*******
ed. The nurse instructs the client to avoid
4.Cantaloupe
consuming which item?
1.Use nail polish to protect the nail beds
from injury. 2.Wear gloves for all activities
The nurse is preparing discharge in- involving the use of both hands.
structions for a client with Raynaud's dis- 3.Stop smoking because it causes cuta-
ease. The nurse should plan to provide neous blood vessel spasm. ********
which instruction to the client? 4.Always wear warm clothing, even in
warm climates, to prevent vasoconstric-
tion.
1.
The nurse is developing a plan of care for Keep the legs aligned with the heart.
a client with varicose veins in whom skin 2.
breakdown occurred over the varicosi- Elevate the legs higher than the
heart.*********
, Saunders NCLEX Comprehensive Review Study Questions
Study online at https://quizlet.com/_di8no0
3.
Clean the skin with alcohol every hour.
ties as a result of secondary infection.
4.
Which is a priority intervention?
Position the client onto the side during
every shift.
The nurse in the medical unit is reviewing
the laboratory test results for a client who
has been transferred from the intensive 1.Heart failure
care unit (ICU). The nurse notes that a 2.Atrial fibrillation
cardiac troponin T assay was performed 3.Myocardial infarction********
while the client was in the ICU. The nurse 4.Ventricular tachycardia
determines that this test was performed
to assist in diagnosing which condition?
The nurse is caring for a client with car-
diac disease who has been placed on
1.Hypotension********
a cardiac monitor. The nurse notes that
2.Flat neck veins
the client has developed atrial fibrillation
3.Complaints of nausea
and has a rapid ventricular rate of 150
4.Complaints of headache
beats/minute. The nurse should next as-
sess the client for which finding?
The nurse is performing an assessment
1.Listening to lung sounds*******
on a client with a diagnosis of left-sided
2.Palpating for organomegaly
heart failure. Which assessment compo-
3.Assessing for jugular vein distention
nent would elicit specific information re-
4.Assessing for peripheral and sacral
garding the client's left-sided heart func-
edema
tion?
1."This is a normal finding." *********
The nurse is participating in a class on
2."This is indicative of atrial flutter."
rhythm strip interpretation. Which state-
3."This is indicative of atrial fibrillation."
ment by the nurse indicates an under-
4."This is indicative of impending rein-
standing of a PR interval of 0.20?
farction."
The nurse in the medical unit is assigned
1.Anxiety related to the need to make
to provide discharge teaching to a client
lifestyle changes 2.Boredom resulting
with a diagnosis of angina pectoris. The
from having already learned the material
nurse is discussing lifestyle changes that
3.An attempt to ignore or deny the need
are needed to minimize the effects of the
to make lifestyle changes*********
disease process. The client continually
