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Pump up on practice questions 67

NCLEX keysClient needs category: Physiological integrityClient needs subcategory: Reduction of risk potentialCognitive level: Analysis

4. A client with a myocardial infarction and cardiogenic shock is placed on an intra-aortic balloon pump (IAPB). If the device is func-tioning properly, the balloon inflates when the:

1. tricuspid valve is closed.2. pulmonic valve is open.3. aortic valve is closed.4. mitral valve is closed.

Answer: 3. An IAPB inflates during diastole when the tricuspid and mitral valves are open and the aortic and pulmonic valves are closed.

NCLEX keysClient needs category: Physiological integrityClient needs subcategory: Physiological adaptationCognitive level: Comprehension

5. A client with unstable angina receives routine applications of nitroglycerin ointment. The nurse should delay the next dose if the client has:

1. atrial fibrillation.2. a systolic blood pressure below

90 mm Hg.3. a headache.4. skin redness at the current site.

Answer: 2. Nitroglycerin is a vasodilator and can lower arterial blood pressure. As a rule,

when the clients systolic blood pressure is below 90 mm Hg, the nurse should delay the dose and notify the physician. Nitroglycerin isnt contraindicated in a client with atrial fibrillation. Headache, a common occur-rence with nitroglycerin isnt a cause for withholding a dose. Application sites should be changed with each dose, especially if skin irritation occurs.

NCLEX keysClient needs category: Physiological integrityClient needs subcategory: Pharmacological and parenteral therapiesCognitive level: Application

6. A client experiences acute myocardial ischemia. The nurse administers oxygen and sublingual nitroglycerin. When assessing an electrocardiogram (ECG) for evidence that blood flow to the myocardium has improved, the nurse should focus on the:

1. widening of the QRS complex.2. frequency of ectopic beats.3. return of the ST segment to baseline.4. presence of a significant Q wave.

Answer: 3. During episodes of myocardial ischemia, an ECG may show ST-segment elevation or depression. With successful treatment, the ST segment should return to baseline. Widening QRS complex, presence of a Q wave, and frequent ectopic beats arent directly indicative of myocardial ischemia.

NCLEX keysClient needs category: Physiological integrityClient needs subcategory: Pharmacological and parenteral therapiesCognitive level: Application

313419NCLEX-RN_Chap03.indd 67313419NCLEX-RN_Chap03.indd 67 4/8/2010 7:01:54 PM4/8/2010 7:01:54 PM

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115-nclex-rn review made incredibly easy, fifth edition (incredibly easy...

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