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NCLEX Cardiac

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What are the nursing interventions for a patient in complete heart block?
Ask patient to make a tight fist - using your index and middle fingers compress both the radial and ulnar arteries to obstruct blood flow to hand - ask pt to relax hand (hand and palm should appear blanched bc flow stopped) - release pressure on ulna
Trendelenburg position for insertion. Pt holds breath to prevent air from entering sinus tract.
Stand behind the victim - wrap arms around waist (IF PREGNANT WRAP ABOVE The BABy) - make a fist with one had and place thumb against abdomen midline - grasp fist with other hand - press into victims abdomen with quick upward thrusts.
(1st) Assess the client for S&S of decreased cardiac output and Notify physician (2nd).

2. What is the necessary lab value to evaluate while a patient is on heparin? What is the normal value?
If feel more than 3 shocks in a row or develop signs of infection at the site.
D/C the med and call the doctor.
PTT. Normal= 30 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PTT= 45-75 sec.
In the first 72 hours!!!!!

3. What will a leg with arterial insufficiency look like?
NO because it isn't sterile so keep out.
Constipation or MAY CAUSE ANKLES TO SWELL (call healthcare provider).
Check for response - activate ERS - open airway head tilt chin lift - check breathing (5-10 sec) - give 2 breaths (1 sec) with visible chest rise - checks brachial pulse (5-10 sec) - locates CPR finger position - deliver 1st cycle of compressions (30
Hair loss - muscle mass loss - pallor when elevated - dependent rubor - and prolonged cap refill time.

4. What is the correct way to insert an oropharyngeal airway?
Changing the way that you live is the first step. STOP SMOKING!!!! <30% FAT In DIET (don't avoid all fat) - lose weight - exercise - limit salt intake - nitro - Angioplasty (stent insertion) or CABG.
Gently insert the oropharyngeal airway by turning it upside down (into U shape) and slide it into the mouth. As continue to insert rotate it so the ends of the U turn downward into an arch shape after it transverses the oral cavity and approaches the
When: using anticoagulants - liver disease - decrease in platelets (less than 150 -000) - hemophilia - using thrombolytic meds - DIC - CA - HIV - chemo - bone marrow problems - and ASA/NSAIDS.
Inspect pulses on chest - inspect the internal jugular veins - palpate the apical pulse - palpate the carotid arteries - and auscultate the heart sounds.

5. Which jugular veins give a more accurate estimate of the jugular vein pressure and pressure in the right atrium?
The internal jugular veins (external are less reliable).
Thromboanglitis obliterans/ Buerger's disease= inflammatory process of arterial wall - veins - and nerves where they become blocked. It is associated with smoking/tobacco use.
When not visable - place the patient in the left lateral position - ask them to exhale fully and stop breathing for a few seconds.
GI - neuro - and cardiac. S&S= yellow/green vision - N&V - bradycardia - and anorexia.

6. What should you do immediately if you suspect someone of developing a hematoma?
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.
Stop What they are doing - sit down and rest - if prescribed nitroglycerin tablets place one under tongue - if it still remains take another tablet in 5 mins - and if still in pain take another after an additional 5 mins - if still pain after 3 table
Pneumothorax and will end up with chest tube to help reinflate lung.
In fatty areas or over major muscles - large breasts - or bony prominences.

7. What are the steps for adult 2 rescuer CPR?
Rescuer arrives with AED - turn AED on - select proper pads and apply - clear victim to analyze - clear victim to shock/press shock - resume chest compressions after 1 shock - delivers cycle of compressions at correct rate - pause to allow other resc
Pallor - diaphoresis - tachypnea - severe tearing chest pain radiating to back - PULSES In ARMS Are STRONG BUT LEG PULSES Are WEAK - low SP02.
(1st) Assess the client for S&S of decreased cardiac output and Notify physician (2nd).
INTERVENE: to control edema and decrease pain patient should be on bed rest with legs elevated six inches above heart level.

8. What is Deep Vein Thrombosis (DVT)?
A disease in which thrombi trap blood in the deep veins of the pelvis and legs.
An inflammation of the pericardium. It may result in MI.
0.5-2.0 ng/ml
Arterial pulse: 60-90 - Amplitude: 4+=strong and bounding - Edema: 0=none - Reflex 2+

9. What landmarks should you be looking for on someone's chest?
Hematuria (tea or coca cola colored) - nosebleeds - gingival bleeding (no medicated mouth wash - flossing - or lemon glycerin swabs) - and bruising (assess for abuse w/o caregiver).
Aortic valve - Pulmonic valve - right ventricle - tricuspid valve - and apex or mitral valve.
Left sternal border
Decreased tissue perfusion. Tx: clot busting treatment must start within 6 hours.

10. What should you remember while taking care of someone with a peripheral arterial occlusion?
Used to detect an abdominal aortic aneurysm. This noninvasive test takes 15 to 30 mins. They apply conductive gel to your abdomen and move a transducer over abdomen to scan blood vessels. Sound waves bouncing off anatomic structures are translated in
Air embolism
NO TED HOSE - NO SHEETS/BLANKETS - NO COMPRESSION DEVICES - (TEACH NO OPEN TOES SHOES). Lambs wool is okay!
Crushing chest pain that lasts 30 mins or longer and may radiate to the neck - shoulders - or jaw - diaphoresis - nausea - and SOB.

11. What is important to remember when taking care of patients with compression devices?
Steroid treatment or a pregnant woman who is retaining water.
You need to maintain use of those devices continually except when the patient is ambulating - bathing - or during physical therapy or skin assessment.
Must be flushed 1x/month with heparin and between treatments.
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.

12. What is the nursing care associated with chemical stress tests (persantine stress test)?
Use sterile gloves and aseptic technique - clean skin over port with alcohol or iodine - insert a 21 or 22 gauge HUBER needle (noncoring - won't break apart) attached to syringe or tubing into the middle of the port until rigid back of port is palpab
Elevated legs - anticoagulation therapy (aggressive: generally IV heparin) - Be alert for signs of PE.
Fourth or fifth intercostal space at or medial to the midclavicular line.
Explain procedure - stress importance of reporting symptoms. INSTRUCT The PATIENT NO TO EAT DRINK OR SMOKE AT LEAST 1 HOUR BEFORE The TEST. EVALUATE PATIENTS HISTORY FOR ANY CARDIAC CONDITIONS OR MEDICATIONS THAT MAY INTERFERE WITH The TEST!!! (No va

13. What are the proper steps to changing a central venous catheter dressing?
International Normalized Ratio measures blood clotting time and compares it to normal values. 1.0=normal. Most people on anticoagulants are 2-3.
It is a sterile procedure so both nurse and patient should wear a mask - arrange sterile field - remove dressing - assess the catheter insertion site for infection - put on sterile gloves - clean the site moving outwardly in a circular motion - apply
Have the patient use the val salva maneuver when the line is being removed (bear down/hold breath) to prevent air from entering where the line was and causing a PE.
Aortic valve - Pulmonic valve - right ventricle - tricuspid valve - and apex or mitral valve.

14. What is INR?
International Normalized Ratio measures blood clotting time and compares it to normal values. 1.0=normal. Most people on anticoagulants are 2-3.
Give furosemide (lasix) 40-60 mg IV - O2 administration - morphine sulfate 3-5 mg IV - have patient sit up with feet lowered (decreases venous return to the heart) - nitroglycerin given sublingual or IV - and rotating tourniquets (can reduce intratho
(S1 - S2) Third left intercostal space
Protamine Sulfate

15. What things should you do to assess cardiovascular status?
Inspect pulses on chest - inspect the internal jugular veins - palpate the apical pulse - palpate the carotid arteries - and auscultate the heart sounds.
It is calculated by checking the brachial BP and the ankle BP. The ankle systolic pressure is divided by the brachial systolic. The NA can perform. 0.97-1 is normal anything below indicates ischemia.
Iodine
Stand behind the victim - wrap arms around waist (IF PREGNANT WRAP ABOVE The BABy) - make a fist with one had and place thumb against abdomen midline - grasp fist with other hand - press into victims abdomen with quick upward thrusts.

16. What factors place you at risk for HTN?
An inflammation of the pericardium. It may result in MI.
One at a time to assess the pulse amplitude and contour.
Having the patient supine is ideal but any position is acceptable so long as in same position for each monitoring session - locate clean and dry sensor sites on the neck (in line with earlobe) and thorax (midaxillary at xiphoid process) - connect lea
BIRTH CONTROL PILL (LEADING CAUSE of HTN In YOUNG WOMEN-45=STILL YOUNG) - BLACK Male (then white male - than black female - then white female) - obesity - smoking - stress - high Na diet - lack of exercise - age - sex - race - or noncompliance.

17. What are the nursing interventions for a patient with premature ventricular contractions?
(1st) Assess the client for signs of decreased cardiac output and Notify the physician (2nd).
Explain procedure - stress importance of reporting symptoms. INSTRUCT The PATIENT NO TO EAT DRINK OR SMOKE AT LEAST 1 HOUR BEFORE The TEST. EVALUATE PATIENTS HISTORY FOR ANY CARDIAC CONDITIONS OR MEDICATIONS THAT MAY INTERFERE WITH The TEST!!! (No va
Inspect pulses on chest - inspect the internal jugular veins - palpate the apical pulse - palpate the carotid arteries - and auscultate the heart sounds.
Difficulty breathing - pain in midchest and shoulder - pale - nausea - and light headedness.

18. What condition can cause left sided heart failure?
Temporary or permanent transvenous PACEMAKER INSERTION - and if the client is symptomatic and showing S&S of decreased cardiac output - GIVE ATROPINE.
Second right intercostal space
Don a protective gown - gloves - and goggles - call Dr - hand pt. emesis basin and raise the HOB 45* (at this angle he can spit out blood and prevent N&V/aspiration - have another nurse firmly press on his nose just below bony part (apply pressure at
Vascular - artery disease causing fluid to back up into the lungs.

19. What is characteristic of ventricular tachycardia?
Rapid ventricular rate with no relationship to atrial activity and QRS complex is wide and bizarre.
Activity intolerance
(S1 - S2) Third left intercostal space
CPR should be done. No defibrillation bc no rhythm to shock (heart already depolarized).

20. What makes the symptoms of superior vena cava syndrome better? Worse?
Don't interfere!
The symptoms improve when the patient is sitting in upright position that promotes drainage but worsen with the client is lying down.
In fatty areas or over major muscles - large breasts - or bony prominences.
High pitched sounds like S1 and S2 (pericardial friction rubs - aortic/mitral regurgitation murmurs). DIAPH(high)ragm

21. What activity should a patient with pericarditis - who is undergoing treatment - be allowed?
4th left intercostal space lower sternal border
0.5-2.0 ng/ml
Maintain BED REST
Premature beats that are not preceded by a P- wave - QRS is wide and bizarre - and the T wave of the premature beat is generally large and in the opposite direction of the QRS.

22. What should the plan of care include for a diagnosis of activity intolerance r/t right sided HF?
Smoking - elevated cholesterol - diabetes - hypertension - old age - and family hx of coronary artery disease.
Include rest periods prior to any activity.
NO NSAIDS or ASA.
Clip the hair to allow good contact between the electrodes and the skin (DONT SHAVE).

23. What are the indications for a chemical stress test (persantine stress test)?
NO because it isn't sterile so keep out.
The internal jugular veins (external are less reliable).
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.
Patient who are unable to tolerate exercise stress testing.

24. What are the steps for infant 1&2 rescuer CPR?
Check for response - activate ERS - open airway head tilt chin lift - check breathing (5-10 sec) - give 2 breaths (1 sec) with visible chest rise - checks brachial pulse (5-10 sec) - locates CPR finger position - deliver 1st cycle of compressions (30
Hair loss - muscle mass loss - pallor when elevated - dependent rubor - and prolonged cap refill time.
Arterial pulse: 60-90 - Amplitude: 4+=strong and bounding - Edema: 0=none - Reflex 2+
Limit the size of the infarction is the goal. Treatment= thrombolytic therapy (tPA) initiated within 6 hours of the first symptoms= standard treatment.

25. What should you explain to the patient about an impedance cardiography test?
Pulmonary edema
It will take 5 mins and he/she should remain quiet for about 1 minute without talking or moving.
Spasms of the arterioles in finger/toes (digits of hands/feet may fall off). Tx: stop smoking - avoid stress & cold - use a vasodilator (calcium channel blocker). No skiing or butcher for career.
No radial artery punctures if negative

26. If a victim is choking but can cough - speak - or breath what should you do?

27. What nursing interventions are associated with a pt. experiencing ventricular fibrillation?
(1ST) BEGIN CARDIOPULMONARY RESUSCITATION (The PT. Is DYING) And NotIFY PHYSICIAN (2ND).
Used in an emergency (Vfib/defib) - used with Vfib or Vtach - NO CARDIAC OUTPUT - client is unconscious - EKG monitor - NO CONSENT NEEDED - begin with 200 Joules and up to 360.
RAndI= Razor - electric - Aspirin - NO - Needles - small gauge - Decrease - needle sticks - and Injury- protect from. No percodan or NSAIDS - no open toed shoes.
Arterial pulse: 60-90 - Amplitude: 4+=strong and bounding - Edema: 0=none - Reflex 2+

28. Where should you place your stethescope to find the tricuspid valve?
Idiopathic
Feeling of fullness in head - tightness around shirt collar - or rings/jewelry that suddenly seem tight - swelling in face - hands - arms - and swollen/cyanotic lips - dyspnea - coughing - hoarseness - chest pain - hemotysis - visable collateral ches
4th left intercostal space lower sternal border
Right atrium - TRICUSPID VALVE (tissue) - right ventricle - PULMONIC VALVE (paper) - lungs - left atrium - MITRAL VALVE (My) - left ventricle - AORTIC VALVE (Assets). Tissue PAPER MY ASSETS!

29. What is a assessment finding with DVT?

30. What is the treatment for someone in ventricular fibrillation?
Second left intercostal space
Direct current shock (defibrillation) and IV anti - arrhythmic drugs (lidocaine - Procainamide - and Bretylium).
Right atrium - TRICUSPID VALVE (tissue) - right ventricle - PULMONIC VALVE (paper) - lungs - left atrium - MITRAL VALVE (My) - left ventricle - AORTIC VALVE (Assets). Tissue PAPER MY ASSETS!
To inhibit thrombus and clot formation.

31. What are the S&S of pulmonary embolism?
In fatty areas or over major muscles - large breasts - or bony prominences.
Pulmonary edema
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.
Deep in the sternomastoid muscle - so look for pulsations in the soft tissue surrounding that area.

32. What are the S&S of aortic dissection?
Pallor - diaphoresis - tachypnea - severe tearing chest pain radiating to back - PULSES In ARMS Are STRONG BUT LEG PULSES Are WEAK - low SP02.
An inflammation of the pericardium. It may result in MI.
In the first 72 hours!!!!!
GI - neuro - and cardiac. S&S= yellow/green vision - N&V - bradycardia - and anorexia.

33. During an Allen's test don't compress one artery _____ the other.
A nosebleed
Stop the medication - address the factors that may have precipitated the event. If life threatening Digibind ay be indicated.
Before
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.

34. What does the device for impedance cardiography consist of?
A complication from a venous access device or port. It is a blockage of the superior vena cava preventing superior blood flow from reaching the heart.
A monitor with four dual electrodes that are applied to the patients neck and thorax.
Ventricular rate is regular at a rate of 40-60 bpm and there is no relationship of P waves to QRS complexes.
MONA=Magnesium sulfate - O2 - Nitroglycerin - Aspirin (mona has a heart so EKG also if select all that apply).

35. Where is the aortic valve landmark on the chest?
They may feel a slight stinging under there tongue when they are dissolving - and they should get a HA (if no HA may not be good bc the pills only last for 6 months). Keep with you at all times.
Second right intercostal space
Aortic valve - Pulmonic valve - right ventricle - tricuspid valve - and apex or mitral valve.
Feeling warm (fire) or tin can taste is expected and will pass.

36. What is the antidote for coumadin?
A fluid accumulation in the pericardial space that compromises cardiac function. It is considered a medical emergency and is a hemodynamic consequence of blood or excess fluid accumulation in the pericardial sac. Common causes are surgical or traumat
Hematuria (tea or coca cola colored) - nosebleeds - gingival bleeding (no medicated mouth wash - flossing - or lemon glycerin swabs) - and bruising (assess for abuse w/o caregiver).
A nosebleed
Vitamin K (aqua myphiton)

37. What is the maintenance for venous access port that isn't being regularly used?
Poorly controlled hypertension
Don't interfere!
Must be flushed 1x/month with heparin and between treatments.
When: using anticoagulants - liver disease - decrease in platelets (less than 150 -000) - hemophilia - using thrombolytic meds - DIC - CA - HIV - chemo - bone marrow problems - and ASA/NSAIDS.

38. What is a chemical stress test (persantine stress test)?
4th left intercostal space lower sternal border
MRI is painless - you must remain still inside a small/noisy space. If you are claustrophobic you may need sedation. Remove all jewelry and other metal objects. If you have any shrapnel - a pacemaker - or any surgically implanted joints - pins - clip
Have the patient use the val salva maneuver when the line is being removed (bear down/hold breath) to prevent air from entering where the line was and causing a PE.
It is a test that examines the hearts response to being stressed by a pharmacologic agent. Persantine and adenosine vasodilate the coronary arteries and cause blood to shunt away from partially occluded coronary vessels. Then dobutamine stresses the

39. What is characteristic of ventricular fibrillation?
Totally disorganized - chaotic pattern - and no discernible waves or complexes.
Don't interfere!
Lowers BP and makes heart beat stronger. SE: flushed face.
Need for follow up blood tests - Need to take oral warfarin for at least 3 months - and to reduce current risk encourage weight loss - smoking cessation - and regular exercise.

40. What should be done for someone on bleeding precautions?
Rapid ventricular rate with no relationship to atrial activity and QRS complex is wide and bizarre.
PT. Normal= 12 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PT= 18-30 sec.
In the first 72 hours!!!!!
RAndI= Razor - electric - Aspirin - NO - Needles - small gauge - Decrease - needle sticks - and Injury- protect from. No percodan or NSAIDS - no open toed shoes.

41. What is a good diagnosis for someone with right sided HF?
Changing the way that you live is the first step. STOP SMOKING!!!! <30% FAT In DIET (don't avoid all fat) - lose weight - exercise - limit salt intake - nitro - Angioplasty (stent insertion) or CABG.
Activity intolerance
Pallor - diaphoresis - tachypnea - severe tearing chest pain radiating to back - PULSES In ARMS Are STRONG BUT LEG PULSES Are WEAK - low SP02.
PT. Normal= 12 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PT= 18-30 sec.

42. What should be taught upon discharge for someone going home on coumadin as a result of a PE?
(1st) Assess LOC - (2nd) if unconscious= begin CPR - and (3rd) Notify physician.
PTT. Normal= 30 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PTT= 45-75 sec.
Need for follow up blood tests - Need to take oral warfarin for at least 3 months - and to reduce current risk encourage weight loss - smoking cessation - and regular exercise.
Direct current cardioversion and digoxin/propranolol (inderal).

43. What should you do if the patient you are applying cardiac monitor electrodes to is hairy?
Don a protective gown - gloves - and goggles - call Dr - hand pt. emesis basin and raise the HOB 45* (at this angle he can spit out blood and prevent N&V/aspiration - have another nurse firmly press on his nose just below bony part (apply pressure at
Clip the hair to allow good contact between the electrodes and the skin (DONT SHAVE).
File toe nails - if have new shoes only wear 2 hrs/day d/t neuropathy can't feel if problem. To decrease pain of claudication massage legs to increase circulation.
After a sheath removal to apply consistent pressure and prevent bleeding. (Ex: after swan ganz removal).

44. What should be done during the insertion of both a CVP catheter and a swan ganz catheter?
Trendelenburg position for insertion. Pt holds breath to prevent air from entering sinus tract.
Maintain BED REST
Changing the way that you live is the first step. STOP SMOKING!!!! <30% FAT In DIET (don't avoid all fat) - lose weight - exercise - limit salt intake - nitro - Angioplasty (stent insertion) or CABG.
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.

45. What is an acute peripheral arterial occlusion?
Hematuria (tea or coca cola colored) - nosebleeds - gingival bleeding (no medicated mouth wash - flossing - or lemon glycerin swabs) - and bruising (assess for abuse w/o caregiver).
Need for follow up blood tests - Need to take oral warfarin for at least 3 months - and to reduce current risk encourage weight loss - smoking cessation - and regular exercise.
Must be flushed 1x/month with heparin and between treatments.
The arteries have narrowed - decreased O2 to tissues= hypoxia to cells.

46. What is labile hypertension?
Vitamin K (aqua myphiton)
Identify the highest point of pulsation and measure from this point to the sternal angle. A measurement of greater than 3 cm= an elevated venous pressure.
BP is elevated or decreased depending on activity.
They may feel a slight stinging under there tongue when they are dissolving - and they should get a HA (if no HA may not be good bc the pills only last for 6 months). Keep with you at all times.

47. What is cardioversion?

48. What should you do immediately for someone experiencing anticoagulant induced epistaxis?
Don a protective gown - gloves - and goggles - call Dr - hand pt. emesis basin and raise the HOB 45* (at this angle he can spit out blood and prevent N&V/aspiration - have another nurse firmly press on his nose just below bony part (apply pressure at
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.
Crushing chest pain that lasts 30 mins or longer and may radiate to the neck - shoulders - or jaw - diaphoresis - nausea - and SOB.
Cardiac tamponade (fluid in pericardial space) and thickening/scarring of the pericardial sac (constrictive pericarditis and possible RHF).

49. What does plan of care include?
Vitamin K (aqua myphiton)
All People Enjoy Time Magazine= Aortic - Pulmonic - ERB's point - Tricuspid - and Mitral/Apex. P(2) E (3) T (4) MA (5) (locations)
Pericardial friction rub - chest pain (sharp and aggravated with breathing) - abnormal EKG findings - possible fever and tachycardia.
Elevated legs - anticoagulation therapy (aggressive: generally IV heparin) - Be alert for signs of PE.

50. What should you teach someone with arterial insufficiency?