Cardiovascular System - NCLEX - HPM

4/15/2020 Cardiovascular System: NCLEX - HPM
Cardiovascular System
Due No due date Points 25 Questions 25 Time Limit 50 Minutes
Allowed Attempts 2
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Attempt History
Attempt Time Score
LATEST Attempt 1 49 minutes 13.5 out of 25
Score for this attempt: 13.5 out of 25

Submitted Apr 15 at 10:56am
This attempt took 49 minutes.
Question 1 1 / 1 pts
The nurse is caring for a neonate with congestive heart failure identifies
which of the following nursing diagnosis as highest priority?
Fatigue.
Activity intolerance
Sleep pattern disturbance.
Correct! Altered tissue perfusion.
https://medpro.instructure.com/courses/36/quizzes/648 1/22
Rationale:
1. Fatigue is an important nursing diagnosis for the baby with

congestive heart failure, but it is not the priority diagnosis.
2. Activity intolerance is an important nursing diagnosis for the

baby with congestive heart failure, but it is not the priority
diagnosis.
3. Sleep pattern disturbance is an important nursing diagnosis for

the baby with congestive heart failure, but it is not the priority
diagnosis.
4. Altered tissue perfusion is the priority diagnosis.
TEST-TAKING TIP: Whenever the test taker is asked to identify

the priority response, it is important to remember that the
acronym CAB—circulation, airway, breathing—should be
followed. When circulation is impaired, there is altered tissue
perfusion. None of the other responses relates to critical
physiological processes.
Question 2 0.5 / 1 pts
A nurse hears a heart murmur on a full-term neonate in the well-baby

nursery. The baby’s color is pink while at rest and while feeding. Which of
the following cardiac defects is consistent with the nurse’s findings?
Select all that apply.
Transposition of the great vessels.
Tetralogy of Fallot.
orrect Answer Ventricular septal defect.
Pulmonic Stenosis.
Correct! Patent Ductus Arteriosus.
Rationale:
1.Transposition of the great vessels is a cyanotic defect that, if it

stands alone, is incompatible with life.
2. Tetralogy of Fallot is a cyanotic defect characterized by four

defects: VSD, pulmonic stenosis, overriding aorta, and
right ventricular hypertrophy.
3. Ventricular septal defect (VSD) is the most common cardiac

defect in neonates. It is an acyanotic defect with a left to right
shunt. Already oxygenated blood reenters the pulmonary
system.
4. Pulmonic stenosis is characterized by a narrowed pulmonic

valve. The blood, therefore, is restricted from entering the
pulmonary artery and the lungs to be oxygenated.
5. Patent ductus arteriosus (PDA) is a very common cardiac

defect in preterm babies. It is an acyanotic defect with a left to
right shunt. Already oxygenated blood reenters the pulmonary
system.
TEST-TAKING TIP: The names of cardiac defects are very

descriptive. Once the test taker remembers the
pathophysiology of each of the defects, it becomes clear how
the blood flow is affected. Of the choices in this question, the
defects that are acyanotic defects, that is, defects that allow
blood to enter the lungs to be oxygenated, are the VSD and
the PDA.
A preterm infant has a patent ductus arteriosus (PDA). Which of the

following explanations should the nurse give to the parents about the
condition?
Hole has developed between the left and right ventricles.
Hypoxemia occurs as a result of the poor systemic circulation.
Correct!
Oxygenated blood is reentering the pulmonary system.
Blood is shunting from the right side of the heart to the left.
RATIONALE:
1. A hole between the left and right ventricles is called a ventricular

septal defect (VSD).
2. Unless the baby is decompensating, this defect rarely results in

cyanosis. The blood is being oxygenated and, although there is
mixed blood, the baby is sufficiently oxygenated.
3. There is a left to right shunt of blood with a PDA, resulting

in oxygenated blood reentering the pulmonary system.
4. There is a left to right shunt rather than a right to left shunt.
A child has been diagnosed with a small ventricular septal defect (VSD).
Which of the following symptoms would the nurse expect to see?
Cyanosis and clubbing of the fingers.
ou Answered
Respiratory distress and extreme fatigue.
orrect Answer
Systolic murmur with no other obvious symptoms.
Feeding difficulties with marked polycythemia.
Rationale:
1. Cyanosis and clubbing are seen in children suffering from

severe cyanotic defects but are not likely to develop with a small
VSD.
2. These symptoms will unlikely develop with a small VSD.
3. This response is correct.
4. Feeding difficulties and polycythemia are seen in children

suffering from severe cyanotic defects.
TEST-TAKING TIP: The VSD—an opening between the

ventricles of the heart—is the most common acyanotic heart
defect seen. The defect leads to a left-to-right shunt because
the left side of the heart is more powerful than the right side
of the heart, causing a murmur. Small VSDs rarely result in
severe symptoms and, in fact, often close over time without
any treatment.
The nurse caring for an infant with congenital cardiac defect is monitoring
the child for which of the following early signs of congestive heart failure?
Select all that apply.
Palpitations.
Correct!
Tachypnea.
Correct!
Tachycardia.
Correct!
Diaphoresis.
Irritability.
Rationale:
2, 3, and 4 are correct.
1. Palpitations are not an early sign of congestive heart failure

(CHF).
2. No matter whether a baby or an adult were developing CHF,

the patient would be tachypneic.

the patient would be tachycardic.

the patient would be diaphoretic.
5. Irritability is not an early sign of CHF.
The term that is most descriptive in the phrase “congestive

heart failure” is the word “failure.” If the test taker remembers
that because of poor functioning the heart is failing to
oxygenate the body effectively, the test taker can remember
the symptoms of the disease. When the body is being starved
of oxygen, the body compensates by increasing respirations
to take in more oxygen and the pulse rate speeds up to move
the oxygenated blood more quickly through the body.
Sweating is also a component of the early stages of the
disease.
In assessing a child with Kawasaki disease, the nurse should recognize

that the childhood communicable disease that poses the greatest danger
for this child is:
Measles.
Mumps.
Rubella.
Correct! Chicken pox.
Answer (D). Salicylate therapy is the current therapy for

Kawasaki’s disease. If the child is exposed to chickenpox, aspirin
should be stopped and the pediatrician notified immediately
because of the drug’s possible association with Reye’s syndrome.
When assessing a child for signs and symptoms of rheumatic fever, which
symptoms should the nurse anticipate?
Correct!
Tachycardia and joint pain.
Bradycardia and swollen joints.
Loss of coordination and pruiritic rash.
Bradycardia and fever.
Answer: (A) Tachycardia, fever, migratory polyarthritis, loss of

coordination, subcutaneous nodules, and a nonpruritic rash are
classic signs f aspirin toxicity.
A parent of a toddler with Kawasaki disease tells the nurse, “I just don’t
know what to do with my child. He’s never acted like this before.” The
nurse’s best reply is:
"Don’t worry. This type of behavior is typical for a toddler.”
Correct!
“Irritability is part of Kawasaki disease, please don’t be embarrassed.”
“Perhaps your child would benefit from stricter limits.”
“You seem to be in need of a referral to our Child Guidance Clinic.”
Answer: (B) Irritability and inconsolability are classic behaviors

associate with the acute phase of Kawasaki’s disease. Parents
need to be informed and supported in their efforts to comfort an
often inconsolable child. Placing the child in a quiet environment
that promotes rest is of value, as is offering respite care to the
family. Toddlers are a difficult age group to deal with when ill, but,
the irritability associated with Kawasaki’s disease exceeds “normal
toddler irritability.
In taking a history for a child with rheumatic fever, which finding should
the nurse consider possibly related to the onset of this condition?
Aspirin given for fever and sore throat.
orrect Answer
Impetigo 3 weeks earlier
Chickenpox 5 weeks earlier.
ou Answered
Mother has a history of mitral stenosis.
Answer: (B). Rheumatic fever is preceded by a recent strep

infection 2-6 weeks before onset. The strep infection can take the
form of a strep throat, impetigo, or scarlet fever. The nurse should
make a notation of this finding in the nurse’s notes and also inform
the MD.
While carding for a child who is receiving digoxin, the nurse should
monitor the therapeutic serum digoxin level, which should range from:
10-20 μg/mL.
Correct!
0.8-2 μg/mL.
Normal Digoxin level.
0.8-2 mg/mL.
15-30 mg/dL
To avoid making a medication error when administering digoxin to a child,

the nurse should always:
Ask the MD to check the dose before giving digoxin.
ou Answered
Double check all calculations before giving digoxin.
orrect Answer
Verify calculation with another nurse before giving digoxin.
Give 1 mL or less of digoxin for any one dose.
Answer: (C). To ensure safety, the nurse should always verify the
calculation with another staff member before administering the
drug.
The parents of a newborn with ventricular septal defect (VSD) ask why
their baby is being sent home instead of undergoing immediate open
heart surgery. The nurse’s best response is:
“Your baby’s condition is too serious for immediate open heart surgery.”
“Ventricular septal defects are not repaired until the infant is older.”
Correct!
“Your baby has a small defect. And we hope that it will close
spontaneously.”
“Your baby must be fully immunized before surgery.”
Answer: (C). 75-80% of all mall ventricular septal defects close

spontaneously, usually during the first 2 years of life. As long as
the infant dose not experience failure-to-thrive or congestive heart
failure, the repair of the ventricular septal defect can be safely
delayed.
The nurse is observing a senior nursing student as he assesses the child

with coartactation of the aorta. Which of the following is a correct way of
assessing the child?
The student assesses the radial pulse only and BP only.
Correct!
The student assesses upper and lower extremity BP and pulses.
The student assesses apical pulse and BP of upper extremity.
The student assesses the BP only.
Answer: (B). Because it is difficult for the blood to pass through

narrowed lumen of the aorta, pressure is high proximal to the
coartation and low distal to it. This results in increased blood
pressure in the upper portions of the body, because of increased
pressure in the subclavian artery, and decreased blood pressure in
the lower extremities. High blood pressure of the upper body
produces headache and vertigo.
The parents of an infant with tetralogy of Fallot ask the nurse why their
infant’s fingers and toes appear “clubbed.” The nurse should inform the
parents that clubbing is:
Part of the anomaly.
Occurs because the infant’s extremities are in a dependent position.
orrect Answer
The result of extracapillaries forming in the tips of the extremities.
ou Answered
Caused by poor venous return.
Answer: (C). Clubbing of the fingers and toes (distended and flat
tips) occurs because of an increase in the number of capillaries
formed in the tips of extremities as the body attempts to send
blood to all body parts.
When reviewing the chart of an infant with tetralogy of fallot (TOF), the
nurse should anticipate which laboratory findings?
anemia
orrect Answer polycythemia
Increased white blood cell count.
ou Answered Decreased hematocrit.
Answer: (B). Polycythemia, an increase in the number of red blood

cells, occurs as the body attempts to provide enough red blood
cells to supply oxygen to all body parts. This is a potential danger
because the increased concentration causes the blood to become
too thick, and clots in the blood vessels may occur, with
consequent complications of thrombophlebitis, embolism, or
cerebrovascular accident.
Which nursing intervention is most effective in preventing rheumatic fever

in children?
Correct!
Refer the children with sore throats for a throat culture.
Include an ECG in the child’s yearly physical examination.
Assess the child for a change in the quality of the pulse.
Assess the child’s blood pressure.
Answer: (A). Rheumatic fever occurs after an infection and is

usually upper respiratory in nature because of Group A beta-
hemolytic streptococcus. Therefore, the cause of all sore throats in
children should be documented via culture to prevent untreated
infections from occurring. The rest are appropriate interventions
AFTER an episode of rheumatic fever because carditis and its
associated potential for permanent cardiac damage requires
careful followup and management.
An infant with ventricular septal defect develops congestive heart failure

and is placed on digoxin therapy twice a day. The infant vomits the
morning dose of digoxin. The most appropriate nursing intervention is to:
orrect Answer
Notify the pediatrician as soon as possible
ou Answered
Take the infant’s pulse for 1 minute and repeat the dose of digoxin.
Skip the dose and give twice the amount at the net dose.
Repeat the dose and chart that the infant vomited.
Anwer: (A). If the infant vomits, the nurse should not repeat the
dose until a pediatrician confirms that it is safe to do so. Vomiting
can be an early sign of digoxin toxicity.
Which at-home care instruction is essential for the nurse to teach the
parents of a child with rheumatic fever?
ou Answered
Monitor intake and output.
orrect Answer
Monitor apical pulse.
Monitor blood pressure.
Monitor oxygen therapy.
Answer: (B). A child with rheumatic fever is often discharged home

on digoxin, so the parents need to be taught to take an apical
pulse. Digoxin slows conduction, and therefore the heart rate, and
strengthens the contractions of the myocardium, thereby improving
cardiac efficiency. If there are changes in pulse rate or quality,
particularly if there is a decrease in rate, the digoxin should be
withheld.
Which I most beneficial in achieving the goal of preventing infection in a

child with cardiac disease?
Give the child extra immunizations.
Keep the child on prophylactic antibiotics.
Correct!
Keep the child away from others who are ill.
Place the child in protective isolation.
Answer: (C). Other children (as well as adults) can often be a

source of infection for the cardiac child. Although friends and
family are important for the child with cardiac disease, they should
have contact with the child only if they are well themselves.
A 3-year old child undergoes a diagnostic cardiac catheterization. On

conclusion of this procedure, the nurses first action should be to assess:
The IV site for patency.
orrect Answer
Peripheral pulses and observe the incision site.
Body temperature.
ou Answered Pain status.
Answer: (B). Assessing peripheral pulses and observing the

incision site should be the nurse’s first action, especially when an
artery was used for catheterization. A loose dressing on an artery
can cause a large blood loss from the incision site in a relatively
short time. Peripheral pulses must be assessed to ensure that
blood flow to the extremity is not obstructed. The child will have
been NPO during the procedure with an IV to prevent dehydration,
so the IV site should be assessed. The IV can be usually
discontinued as soon as the child is taking adequate oral fluids.
Which statement made by the parents of a child with Kawasaki’s disease

indicated that the parents understood the nurse’s teaching regarding
signs of aspirin toxicity?
“We’ll call the pediatrician immediately if our child develops vomiting or a

rash.”
“We’ll call the pediatrician immediately if our child develops a fever or a

rash.”
Correct!
“We’ll call the pediatrician immediately if our child tells us he hears ringing
in his ears.”
“We’ll call the pediatrician immediately if our child starts to breathe slowly.”
Answer: Ringing in the ears (tinnitus), headache, dizziness,

hyperpnea, and confusion are signs of aspirin toxicity. The rest are
not associated to aspirin toxicity.
A child has been diagnosed with rheumatic fever. Which statement by the
mother indicates an understanding of rheumatic fever?
“I should avoid giving my child aspirin for the arthritic pain.”
orrect Answer
“It’s very upsetting that my child must take penicillin until he’s 20 years
old.”
ou Answered
“I need to wear a gown, gloves, and mask to stay in my child’s room.”
“I don’t know how I’ll be able to keep my child away from his sister when
he gets home.”
Answer: (B) Rheumatic fever is an acquired autoimmune-complex

disorder that occurs 1-3 weeks after an infection of group A beta-
hemolytic streptococci, in many cases as a result f strep throat that
hasn’t been treated with antibiotics. To prevent additional heart
damage from future attacks, the child must take penicillin or
another antibiotic until the age of 20 or for 5 years after the attack,
whichever is longer. Children shouldn’t be given aspirin because it
may result in Reye’s syndrome. Rheumatic fever isn’t contagious,
so isolation precautions aren’t necessary.
A nurse is caring for a child with a cyanotic heart defect. Which signs
should the nurse expect to observe?
Cyanosis, hypertension, clubbing and lethargy.
ou Answered
Cyanosis, hypotension, crouching, and lethargy.
orrect Answer
Cyanosis, irritability, clubbing, and crouching.
Cyanosis, confusion, clonus, and crouching.
Answer: (C). The child with a cyanotic heart defect has cyanosis
along with crabbiness (irritability), clubbing of the digits, and
crouching or squatting. The child with cyanotic heart defect doesn’t
typically have hypertension, lethargy, confusion, or clonus.
A nurse is caring for an infant with tetralogy of Fallot. Which drug should
the nurse anticipate administering during a tet spell?
Propranolol (Inderal).
Correct! Morphine
Meperidine (Demerol).
Furosemide (Lasix)
Answer: B. The nurse should anticipate administering morphine

during a tet spell to decrease the associated infundibular spasm.
Propranolol may be administered as a preventive measure in an
infant with tetralogy of Fallot but isn’t administered during a tet
spell. Furosemide and meperidine aren’t appropriate agents for an
infant experiencing a tet spell.
The nurse is monitoring an infant with congenital heart disease closely for
signs of heart failure (HF). The nurse should assess the infant for which
early sign of HF?
Pallor
Cough
orrect Answer Tachycardia.
ou Answered Shallow breathing.
Answer: (C). Heart Failure (HF) is the inability of the heart to pump
a sufficient amount of blood to meet the oxygen and metabolic
needs of the body. The early signs of HF include tachycardia,
tachypnea, profuse scalp sweating, fatigue and irritability, sudden
weight gain, and respiratory distress. A cough may occur in HF as
a result of mucosal swelling and irritation, but is not an early sign.
Pallor may be noted in an infant with HF, but is not an early sign.
Quiz Score: 13.5 out of 25

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4/15/2020 Cardiovascular System: NCLEX - HPM

Take the Quiz Again

Score for this attempt: 13.5 out of 25

Sleep pattern disturbance.

Correct! Altered tissue perfusion.

1. Fatigue is an important nursing diagnosis for the baby with

2. Activity intolerance is an important nursing diagnosis for the

3. Sleep pattern disturbance is an important nursing diagnosis for

4. Altered tissue perfusion is the priority diagnosis.

TEST-TAKING TIP: Whenever the test taker is asked to identify

Question 2 0.5 / 1 pts

A nurse hears a heart murmur on a full-term neonate in the well-baby

Transposition of the great vessels.

orrect Answer Ventricular septal defect.

Correct! Patent Ductus Arteriosus.

1.Transposition of the great vessels is a cyanotic defect that, if it

2. Tetralogy of Fallot is a cyanotic defect characterized by four

right ventricular hypertrophy.

3. Ventricular septal defect (VSD) is the most common cardiac

4. Pulmonic stenosis is characterized by a narrowed pulmonic

5. Patent ductus arteriosus (PDA) is a very common cardiac

TEST-TAKING TIP: The names of cardiac defects are very

A preterm infant has a patent ductus arteriosus (PDA). Which of the

Hole has developed between the left and right ventricles.

Hypoxemia occurs as a result of the poor systemic circulation.

1. A hole between the left and right ventricles is called a ventricular

2. Unless the baby is decompensating, this defect rarely results in

3. There is a left to right shunt of blood with a PDA, resulting

4. There is a left to right shunt rather than a right to left shunt.

Cyanosis and clubbing of the fingers.

Feeding difficulties with marked polycythemia.

1. Cyanosis and clubbing are seen in children suffering from

2. These symptoms will unlikely develop with a small VSD.

3. This response is correct.

4. Feeding difficulties and polycythemia are seen in children

TEST-TAKING TIP: The VSD—an opening between the

2, 3, and 4 are correct.

1. Palpitations are not an early sign of congestive heart failure

2. No matter whether a baby or an adult were developing CHF,

3. No matter whether a baby or an adult were developing CHF,

4. No matter whether a baby or an adult were developing CHF,

5. Irritability is not an early sign of CHF.

The term that is most descriptive in the phrase “congestive

In assessing a child with Kawasaki disease, the nurse should recognize

Correct! Chicken pox.

Answer (D). Salicylate therapy is the current therapy for

Bradycardia and swollen joints.

Loss of coordination and pruiritic rash.

Bradycardia and fever.

Answer: (A) Tachycardia, fever, migratory polyarthritis, loss of

"Don’t worry. This type of behavior is typical for a toddler.”

“Perhaps your child would benefit from stricter limits.”

“You seem to be in need of a referral to our Child Guidance Clinic.”

Answer: (B) Irritability and inconsolability are classic behaviors

Aspirin given for fever and sore throat.

Chickenpox 5 weeks earlier.

Answer: (B). Rheumatic fever is preceded by a recent strep

Normal Digoxin level.

To avoid making a medication error when administering digoxin to a child,

Ask the MD to check the dose before giving digoxin.

Give 1 mL or less of digoxin for any one dose.

“Your baby must be fully immunized before surgery.”

Answer: (C). 75-80% of all mall ventricular septal defects close