Med Surge Ch. 31: Cardiac Disorders NCLEX Questions
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A patient with heart failure has an ejection fraction of 25%. What
does this information indicate to the nurse about the patient's
health status?
1. Ventricular function is severely impaired
1. Normal ejection fraction is 60%. An ejection fraction of 25% indi2. Cardiac output is greater than normal, which overtaxes the
cates severe impairment of ventricular function; CO is decreased.
heart
3. The amount of blood being ejected from the ventricles is within
normal limits
4. Twenty-five percent of the blood entering the ventricle remains
in the ventricle after systole
A patient admitted 24 hours ago previously with heart failure has
lost 1 kg of weight, has a heart rate of 88, which was 105 on
3. The main goals for care of heart failure are to slow its proadmission, and now has crackles only in the bases of the lungs. gression, reduce cardiac workload, improve cardiac function, and
How should the nurse interpret these assessment findings?
control fluid retention. A weight loss of 1 kg and crackles in the
lung bases indicate control of fluid retention. A HR of 88 indicates
1. More aggressive treatment is needed
reduced cardiac workload and improved cardiac function. The
2. The patient's condition unchanged from admissions
patient's condition has improved since admission. Because the
3. The treatment regimen is achieving the desired effect
patient continues to have crackles in the lungs, heart failure has
4. No further treatment is required at this time because the failure not completely resolved.
has resolved
A patient is diagnosed with left ventricular failure. Which findings 1,4,5
should the nurse recognize as being consistent with this diagnosis? (Select all that apply)
In left ventricular failure, the CO falls and pressure in the pulmonary vascular system increases. Fatigue is a common early
1. Fatigue
manifestation. Pulmonary congestion causes shortness of breath
2. Substernal chest pain during exercise
with minimal exertion. On auscultation of the lungs, inspiratory
3. cm jugular vein distention at 30 degrees
crackles may be heard in the lung bases. Jugular vein distention is
4. Bilateral inspiratory crackles to midscapulae
a manifestation of right ventricular failure. Chest pain with exercise
5. Complaints of shortness of breath with minimal exertion
can be due to angina pectoris or valvular disease.
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The nurse is caring for a patient undergoing pulmonary artery
pressure monitoring. What should the nurse include when caring
Calibrating and leveling the system ring each shift ensures accufor this patient? (Select all that apply)
racy and consistency of measurements. To prevent infection, the
tubing to the insertion site should be changed every 72 hours.
1. Maintain flush solution flow by gravity
There should be 300 mmHg of pressure on the flush solution at
2. Calibrate and level the system every shift
all times to prevent clot formation and catheter occlusion. The
3. Secure the IV line to the bed linens
IV lines should not be secured to the bed linens. This could
4. Change tubing to the insertion site every 72 hours
lead to accidental dislodging. Pressure trends and not individual
5. Report waveform dampening during wedge pressure measurereadings should be monitored. Individual readings may not reflect
ments
the patient's true status.
A patient experiencing acute pulmonary edema is prescribed
morphine sulfate 2-5 mg IV as needed for pain and dyspnea. What 1. Morphine is administered IV to relieve anxiety and improve the
action should the nurse take with this prescribed medication?
efficacy of breathing. It also is a vasodilator that reduces venous
return and lowers left atrial pressure. The nurse should provide
1. Administer the drug as ordered, monitoring respiratory status the medication and monitor the patient's respiratory status. The
2. Withhold the drug until the patient's respiratory status improves medication should not be withheld to wit for the patient's respira3. Questions the order because no time intervals have been
tory status to improve. The medication order is correct as written
specified
and does not need to be questioned. The medication is not being
4. Administer the drug only when the patient complains of chest used to treat chest pain.
pain
The nurse notes a grating heart sound when auscultating the
apical pulse of a patient with pericarditis. What should the nurse
do with this assessment data?
4. A pericardial friction rub, a grating sound, is a characteristic sign
of pericarditis so it is expected, but should be documented in the
1. Obtain an ECG
patient's record. An electrocardiogram is not needed after auscul2. Initiate resuscitation measures
tating this sound. The patient does not need to be resuscitated.
3. Immediately notify the physician
4. Note the finding in the patient's medical record
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Med Surge Ch. 31: Cardiac Disorders NCLEX Questions
Study online at https://quizlet.com/_207v62
The nurse is planning care for a patient with acute infective
endocarditis. What would be an appropriate goal of nursing care
4. Antibiotic therapy effectively treats infective endocarditis in most
for this patient?
cases. The goal of therapy is to eradicate the infecting organism
from the blood and vegetative lesions in the heart. Since mi1. Resume usual activities within 1 week of treatment
croorganisms may have a fibrin covering that protects them from
2. Relate the benign and self-limiting nature of the disease
antibiotic therapy, an extended course of multiple IV antibiotics is
3. Consider cardiac transplantation as a viable treatment option
required.
4. State the importance of continuing IV antibiotic therapy as
ordered
The nurse is assessing heart sounds of a patient scheduled for
mitral valve replacement surgery. Which sound should the nurse
4. The murmur of mitral valve stenosis would be heard during
expect to auscultate in this patient?
diastole when blood is flowing through the stenotic valve from the
atrium to the ventricle at the apex of the heart. A cardiac heave and
1. Cardiac heave
S3 and S4 heart sounds are associated with aortic regurgitation.
2. Muffled heart sounds
Muffled heart sounds are associated with cardiac tamponade.
3. S3 and S4 heart sounds
4. Diastolic murmur heard at the apex
A patient considering heart valve replacement asks if a biologic or
mechanical valve is better to use. How should the nurse respond?
1. Biologic valves tend to be more durable than mechanical valves.
2. The need to take drugs to prevent rejection of biologic tissue is
a major consideration
3. Clotting is a risk with mechanical valves, necessitating anticoagulant drug therapy after insertion
4. Endocarditis is a risk following valve replacement that is more
easily treated with mechanical valves
3. Lifetime anticoagulant therapy to prevent clot formation is necessary following insertion of a mechanical valve. Biologic valves
are prone to deterioration. Drugs to prevent tissue rejection are
not needed after biologic valve replacement surgery. Infections
are easier to treat after biologic valve replacement surgery
The parents of a young athlete who collapsed and dies due to
hypertrophic cardiomyopathy ask how it is possible that their son
had no symptoms of this disorder before experiencing sudden
4. In hypertrophic cardiomyopathy, manifestations may not develcardiac death. How should the nurse respond to the parents?
op l the demand for oxygen increases, such as with athletes during
activity, causing sudden death due to a ventricular dysrythmia.
1. It is likely that your son had symptoms of the disorder before Hypertrophic cardiomyopathy is characterized by eased complihe died, but he may not have thought them important enough to ance of the left ventricle and hypertrophy of the ventricle muscle
tell someone about.
mass. This impairs ventricular filling, leading to small end-diastolic
2. In this type of cardiomyopathy, the ventricle does not fill nor- volumes and low cardiac output. It may be asymptomatic for many
mally. During exercise, heart may not be able to meet the body's years, but symptoms typically occur when increased oxygen deneeds for blood and oxygen
mand causes increased ventricular contractility. They may develop
3. Cardiomyopathy results in destruction and scarring of cardiac suddenly during or after physical activity; in children and young
muscle cells. As a result, the ventricle may rupture during stren- adults, sudden cardiac death may be the first sign of the disorder.
uous exercise, leading to sudden death
This type of cardiomyopathy does not lead to ventricle rupture
4. Exercise causes the heart to contract more forcefully, and can during exercise.
lead to changes in the heart's rhythm or the outflow of blood from
the heart in people with hypertrophic cardiomyopathy.
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