CARDIAC DISORDERS NCLEX ACTUAL
EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
A pt w/ endocarditis develops sudden leg pain w/ pallor, tingling, &
a loss of peripheral pulses. The initial nursing intervention should
be to do which of the following?
1. Notify the physician about these findings.
2. Elevate the leg above the level of the heart.
3. Wrap the extremity in a loose, warm blanket. Apply a foot cradle.
4. Perform passive range of motion (PROM) exercises to stimulate
circulation. -Answer:- 3
Rationale 1: The physician should be notified after the nurse wraps
the leg in a loose, warm blanket to maintain temperature & protect
it from injury.
Rationale 2: The leg should not be elevated above the heart because
this can worsen the ischemia.
Rationale 3: The pt is exhibiting symptoms of acute arterial
occlusion due to possible embolization of a vegetative lesion. W/out
immediate intervention, tissue ischemia & necrosis will ensue &
,ultimately loss of the extremity. The nurse should first wrap the leg
in a loose, warm blanket to maintain temperature & protect from
injury, then notify the physician.
Rationale 4: Passive ROM exercises will increase tissue demand for
oxygen & increase ischemia.
A pt, newly diagnosed w/ heart failure, is prescribed 40 mg of
furosemide (Lasix) to be given IV push. Knowing that the pt is also
prescribed digoxin (Lanoxin), the nurse should review which
laboratory result?
1. sodium level
2. digoxin level
3. creatinine level
4. potassium level -Answer:- 4
Rationale 1: Furosemide can cause hyponatremia but the risk of
hypokalemia has more severe consequences in this situation.
Rationale 2: Heightened digoxin effect can occur in the pt w/
hypokalemia.
Rationale 3: No data indicates renal insufficiency; therefore
creatinine level is not relevant.
,Rationale 4: Serum potassium level is measured in the pt receiving
digoxin & furosemide. Heightened digoxin effect can occur in the pt
w/ hypokalemia. Hypokalemia also predisposes the pt to ventricular
dysrhythmias.
A pt is admitted w/ acute pericarditis. When auscultating heart
sounds, the nurse should ask the pt to do which of the following?
1. Sit, lean forward, & auscultate at the left lower sternal border.
2. Lay supine & breathe quietly while auscultating for expiratory
wheezes.
3. Sit upright & auscultate the outer aspects of the upper lobes for
vesicular breath sounds.
4. Sit, lean forward, & auscultate at the second right intercostal
space, near the sternal border. -Answer:- 1
Rationale 1: Pericardial friction rub is the characteristic sign of
pericarditis & can be heard best at the left lower sternal border
when the pt is sitting & leans forward. The rub is usually heart on
expiration & may be constant or intermittent.
Rationale 2: Pericardial friction rub is the characteristic sign of
pericarditis & can be heard best at the left lower sternal border
when the pt is sitting & leans forward.
, Rationale 3,4: Auscultating lung sounds for expiratory wheezes &
vesicular breath sounds is done, but does not focus on the
pericardial friction rub.
A pt is being discharged from the healthcare facility following
surgical replacement of a mitral valve w/ a mechanical valve. The pt
asks the nurse how much longer he will need to take warfarin
(Coumadin). What is the nurse's best response?
1. "You will be on it for the rest of your life because you have a
mechanical valve."
2. "That will depend upon your surgeon. Ask him when you go to
your office visit."
3. "You will be on it for the rest of your life because you have a
biologic tissue valve."
4. "You will be told when to stop, which means your mechanical
prosthetic valve is probably healed & there is minimal risk of clots."
-Answer:- 1
Rationale 1: Long-term anticoagulation is necessary w/ a
mechanical prosthetic valve, due to the risk of development of clots
on the valve.
EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
A pt w/ endocarditis develops sudden leg pain w/ pallor, tingling, &
a loss of peripheral pulses. The initial nursing intervention should
be to do which of the following?
1. Notify the physician about these findings.
2. Elevate the leg above the level of the heart.
3. Wrap the extremity in a loose, warm blanket. Apply a foot cradle.
4. Perform passive range of motion (PROM) exercises to stimulate
circulation. -Answer:- 3
Rationale 1: The physician should be notified after the nurse wraps
the leg in a loose, warm blanket to maintain temperature & protect
it from injury.
Rationale 2: The leg should not be elevated above the heart because
this can worsen the ischemia.
Rationale 3: The pt is exhibiting symptoms of acute arterial
occlusion due to possible embolization of a vegetative lesion. W/out
immediate intervention, tissue ischemia & necrosis will ensue &
,ultimately loss of the extremity. The nurse should first wrap the leg
in a loose, warm blanket to maintain temperature & protect from
injury, then notify the physician.
Rationale 4: Passive ROM exercises will increase tissue demand for
oxygen & increase ischemia.
A pt, newly diagnosed w/ heart failure, is prescribed 40 mg of
furosemide (Lasix) to be given IV push. Knowing that the pt is also
prescribed digoxin (Lanoxin), the nurse should review which
laboratory result?
1. sodium level
2. digoxin level
3. creatinine level
4. potassium level -Answer:- 4
Rationale 1: Furosemide can cause hyponatremia but the risk of
hypokalemia has more severe consequences in this situation.
Rationale 2: Heightened digoxin effect can occur in the pt w/
hypokalemia.
Rationale 3: No data indicates renal insufficiency; therefore
creatinine level is not relevant.
,Rationale 4: Serum potassium level is measured in the pt receiving
digoxin & furosemide. Heightened digoxin effect can occur in the pt
w/ hypokalemia. Hypokalemia also predisposes the pt to ventricular
dysrhythmias.
A pt is admitted w/ acute pericarditis. When auscultating heart
sounds, the nurse should ask the pt to do which of the following?
1. Sit, lean forward, & auscultate at the left lower sternal border.
2. Lay supine & breathe quietly while auscultating for expiratory
wheezes.
3. Sit upright & auscultate the outer aspects of the upper lobes for
vesicular breath sounds.
4. Sit, lean forward, & auscultate at the second right intercostal
space, near the sternal border. -Answer:- 1
Rationale 1: Pericardial friction rub is the characteristic sign of
pericarditis & can be heard best at the left lower sternal border
when the pt is sitting & leans forward. The rub is usually heart on
expiration & may be constant or intermittent.
Rationale 2: Pericardial friction rub is the characteristic sign of
pericarditis & can be heard best at the left lower sternal border
when the pt is sitting & leans forward.
, Rationale 3,4: Auscultating lung sounds for expiratory wheezes &
vesicular breath sounds is done, but does not focus on the
pericardial friction rub.
A pt is being discharged from the healthcare facility following
surgical replacement of a mitral valve w/ a mechanical valve. The pt
asks the nurse how much longer he will need to take warfarin
(Coumadin). What is the nurse's best response?
1. "You will be on it for the rest of your life because you have a
mechanical valve."
2. "That will depend upon your surgeon. Ask him when you go to
your office visit."
3. "You will be on it for the rest of your life because you have a
biologic tissue valve."
4. "You will be told when to stop, which means your mechanical
prosthetic valve is probably healed & there is minimal risk of clots."
-Answer:- 1
Rationale 1: Long-term anticoagulation is necessary w/ a
mechanical prosthetic valve, due to the risk of development of clots
on the valve.
