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Physiological Adaptation

NCLEX Cardiac Practice Questions

Quick answer

Cardiac questions test whether you can recognize a heart that is failing, bleeding, or beating wrong and act in the right order. They live in Physiological Adaptation, which is about 11 to 17 percent of the exam, and the heart is the most tested organ system in that category.

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The cardiac questions on the NCLEX are mostly about recognition and sequencing, not pharmacology. You get a client with crushing chest pain, a client with pink frothy sputum, a monitor showing a wide fast rhythm, or a groin site that has started to swell after a catheterization, and you have to decide what the nurse does right now. The trap here is picking the most dramatic sounding answer instead of the one that comes first. Students see "ventricular tachycardia" and jump straight to defibrillation without checking whether the client has a pulse, or they call the provider about a dissolving MI before anyone has put oxygen on the client. Slow down, ask what will kill the client fastest, and fix that. The 10 questions below are built around those decision points.

Practice questions

1

A client arrives at the emergency department with substernal chest pressure that started 40 minutes ago, radiates to the left jaw, and has not eased with rest. The client is pale and diaphoretic. Which action should the nurse take first?

  1. ADraw a troponin level and send it to the lab stat
  2. BObtain a 12-lead electrocardiogram
  3. CAsk the client to rate the pain and describe its quality
  4. DStart a second large bore intravenous line
Show answer

Answer: B

The 12-lead ECG is the fastest way to find out whether this is an ST elevation MI, and the goal is to have it done and read within 10 minutes of arrival because it decides whether the client goes to the cath lab. Everything else happens around it.

Why the others are wrong

Troponin (A) is drawn early but takes time to rise and does not change the first 10 minutes of care. A full pain assessment (C) can be done while the leads are going on, not before. A second IV (D) is useful but does not identify the problem or open a blocked artery.

2

A client with a suspected myocardial infarction has oxygen saturation of 91 percent on room air and reports chest pain rated 8 of 10. The provider orders are available. Which order should the nurse carry out first?

  1. AApply oxygen by nasal cannula
  2. BGive the first dose of aspirin
  3. CGive sublingual nitroglycerin
  4. DGive intravenous morphine
Show answer

Answer: A

The client is hypoxic, and an oxygen saturation under 94 percent in a suspected MI means the ischemic muscle is getting even less oxygen. Oxygen goes on first because it is fast, noninvasive, and addresses the most immediate threat. Then the nurse works through aspirin, nitroglycerin and morphine.

Why the others are wrong

Aspirin (B) is given very early, but a hypoxic client needs oxygen before anything is swallowed. Nitroglycerin (C) requires a blood pressure check first and is not the first step in a client with low saturation. Morphine (D) is reserved for pain that does not respond to nitroglycerin and can depress breathing in a client already struggling.

3

A nurse is comparing two clients on a telemetry unit. Client 1 has chest pain that starts with exertion and stops within 5 minutes of sitting down. Client 2 has chest pain that woke him from sleep, has lasted 25 minutes, and is more severe than previous episodes. Which statement correctly describes these clients?

  1. ABoth clients have stable angina and need activity teaching
  2. BClient 1 has stable angina, client 2 has unstable angina and needs immediate evaluation
  3. CClient 2 has stable angina because the pain occurred at rest
  4. DClient 1 has unstable angina because the pain is triggered by activity
Show answer

Answer: B

Stable angina is predictable, brought on by exertion, and relieved by rest or nitroglycerin. Unstable angina is new, happens at rest, lasts longer, or is worse than before, and it is treated as an acute coronary syndrome until an MI has been ruled out.

Why the others are wrong

Client 2 does not fit stable angina (A) because the pain came at rest and lasted 25 minutes. Pain at rest is the hallmark of unstable, not stable, angina (C). Exertional pain that resolves with rest is the classic stable pattern, so D has it backwards.

4

A nurse is assessing a client admitted with heart failure. Which group of findings most strongly suggests the client has right-sided heart failure?

  1. ACrackles in both lung bases, orthopnea, and a dry nighttime cough
  2. BJugular venous distention, ascites, and 3+ pitting edema of both ankles
  3. CPink frothy sputum, oxygen saturation of 86 percent, and restlessness
  4. DS3 heart sound, fatigue with activity, and nocturia
Show answer

Answer: B

When the right ventricle fails, blood backs up into the systemic venous circulation. The signs show up in the neck veins, the liver and abdomen, and the legs. Think "right equals rest of the body."

Why the others are wrong

Crackles, orthopnea and cough (A) are left-sided findings because blood backs up into the lungs. Pink frothy sputum with hypoxia (C) is acute pulmonary edema, the extreme end of left-sided failure. An S3 with fatigue (D) can happen in either type and does not point to the right side specifically.

5

A client with a history of heart failure suddenly becomes restless and anxious, is coughing up pink frothy sputum, has a respiratory rate of 34, and has crackles throughout both lungs. Which action should the nurse take first?

  1. ASit the client upright with the legs dangling over the side of the bed
  2. BObtain a chest x-ray to confirm pulmonary edema
  3. CInsert an indwelling urinary catheter to measure output
  4. DLay the client flat and raise the foot of the bed
Show answer

Answer: A

This is acute pulmonary edema. Sitting the client bolt upright with the legs down uses gravity to pool blood in the lower body, which cuts the amount of blood returning to an overloaded left ventricle and lets the client breathe. It takes seconds and the nurse does it while calling for help and applying oxygen.

Why the others are wrong

A chest x-ray (B) confirms what the nurse can already see and delays treatment. A urinary catheter (C) is useful once diuresis starts but is not the first move. Lying flat with the legs raised (D) pushes more blood into the chest and makes the lungs wetter.

6

A client with newly diagnosed atrial fibrillation asks the nurse why the provider is so concerned about a rhythm that only makes him feel "a little fluttery." Which response by the nurse is best?

  1. A"The irregular beat weakens your heart muscle and will cause a heart attack."
  2. B"Because the upper chambers are quivering instead of squeezing, blood can pool and form clots that may travel to your brain and cause a stroke."
  3. C"Atrial fibrillation usually turns into a lethal rhythm within a few hours if it is not corrected."
  4. D"The main danger is that your blood pressure will drop too low to feel a pulse."
Show answer

Answer: B

In atrial fibrillation the atria do not contract effectively, so blood sits in the atrial appendage and clots. A clot that breaks loose can lodge in a cerebral artery. Stroke prevention is why anticoagulation and rhythm or rate control matter so much.

Why the others are wrong

Atrial fibrillation does not directly cause an MI (A). It is not a lethal rhythm by itself and does not routinely deteriorate into one in hours (C). Many clients tolerate the blood pressure well, and a pulseless state is not the typical risk (D).

7

A nurse on a step-down unit sees ventricular tachycardia on a client's monitor. The client is awake, talking, and has a blood pressure of 104/68 mm Hg and a palpable radial pulse. Which action should the nurse take first?

  1. ABegin chest compressions at 100 to 120 per minute
  2. BPrepare for immediate unsynchronized defibrillation
  3. CStay with the client, apply oxygen, and notify the provider for antiarrhythmic treatment or synchronized cardioversion
  4. DAsk the client to bear down and cough forcefully, then document the rhythm
Show answer

Answer: C

Ventricular tachycardia with a pulse in a stable client is treated with medication, or synchronized cardioversion if the client becomes unstable. The nurse stays at the bedside because the rhythm can become pulseless at any moment, and the first thing the nurse checks in any VT question is whether there is a pulse.

Why the others are wrong

Compressions (A) are for a client with no pulse. Unsynchronized defibrillation (B) is for pulseless VT or ventricular fibrillation, not a client who is awake and talking. Vagal maneuvers (D) are for supraventricular rhythms and do nothing for VT.

8

A client who had a stab wound to the left chest is now hypotensive at 82/60 mm Hg, has distended neck veins, and the nurse can barely hear heart sounds through the stethoscope. Which complication should the nurse suspect and report immediately?

  1. ATension pneumothorax
  2. BCardiac tamponade
  3. CHemorrhagic shock
  4. DLeft ventricular failure
Show answer

Answer: B

Hypotension, jugular venous distention and muffled heart sounds are Beck's triad, the classic picture of cardiac tamponade. Blood filling the pericardial sac squeezes the heart so it cannot fill, and the client needs an emergency pericardiocentesis or surgery.

Why the others are wrong

A tension pneumothorax (A) also causes distended neck veins and hypotension but presents with absent breath sounds on one side and tracheal shift, not muffled heart sounds. In hemorrhagic shock (C) the neck veins are flat because the client has lost volume. Left ventricular failure (D) presents with pulmonary congestion and would not develop acutely from a chest wound in this way.

9

A client is being discharged after placement of a permanent pacemaker. Which statement by the client shows that teaching has been effective?

  1. A"I will count my pulse every morning and call if it drops below the rate my pacemaker is set for."
  2. B"I can go back to lifting weights with my left arm as soon as I get home."
  3. C"I should stand right next to the microwave while it runs to make sure the pacemaker is working."
  4. D"I will keep my cell phone in the shirt pocket directly over the device so I do not lose it."
Show answer

Answer: A

A pulse below the programmed rate means the pacemaker may not be firing, and the client needs to report it. Daily pulse checks are a core part of pacemaker teaching, along with carrying the device card and keeping follow-up appointments.

Why the others are wrong

The arm on the side of the implant is kept below shoulder level and free of heavy lifting for several weeks so the leads do not dislodge (B). Household microwaves are safe, but the client does not need to test the device by standing next to one (C). Cell phones should be held at the opposite ear and kept at least 6 inches away from the generator, not stored over it (D).

10

A client returned to the unit 2 hours ago after a cardiac catheterization through the right femoral artery. Which finding should the nurse report to the provider immediately?

  1. AThe client reports mild soreness at the puncture site
  2. BThe right pedal pulse is weaker than the left and the right foot feels cool
  3. CThe client has voided 350 mL of clear yellow urine
  4. DThe client asks when he can get out of bed
Show answer

Answer: B

A weak or absent distal pulse with a cool foot on the catheterized side suggests arterial occlusion from a clot or spasm at the puncture site. This is a limb-threatening emergency, and the nurse reports it right away while continuing to check the site for bleeding or hematoma.

Why the others are wrong

Mild soreness at the site (A) is expected. Good urine output (C) is a reassuring sign that the kidneys are clearing the contrast dye. Wanting to get up (D) is a teaching moment about keeping the leg straight for the ordered time, not a problem to report.

Quick tips

  • In any MI question, get the 12-lead ECG within 10 minutes and oxygen on if the saturation is under 94 percent. Troponin confirms damage but it starts rising after 3 to 6 hours and stays up for days, so a normal first troponin does not rule anything out.
  • Left-sided failure backs up into the lungs (crackles, orthopnea, frothy sputum). Right-sided failure backs up into the body (neck veins, liver, ankles). If the question gives you both, the left side usually failed first.
  • VT with a pulse gets medication or synchronized cardioversion. VT without a pulse gets CPR and defibrillation. Read for the pulse before you pick anything.
  • Beck's triad for tamponade: low blood pressure, distended neck veins, muffled heart sounds. Pulsus paradoxus (systolic drop over 10 mm Hg on inspiration) is the fourth clue if the question offers it.
  • After a cardiac cath, check the site and the pulses below it every 15 minutes at first, keep the leg straight, push fluids to flush the contrast, and watch the creatinine for the next 48 hours. In a hypertensive crisis, lower the pressure gradually (about 20 to 25 percent in the first hour) because a sudden drop can stroke the client.

Related topics

FAQ

What is the difference between stable and unstable angina on the NCLEX?

Stable angina comes with exertion, lasts a few minutes, and goes away with rest or one nitroglycerin tablet. Unstable angina is new, happens at rest, lasts longer than 15 to 20 minutes, or is worse than the usual pattern. Treat unstable angina as a possible MI and expect the question to want immediate assessment, not activity teaching.

How do I know if the heart failure is left sided or right sided?

Ask where the blood is backing up. Left side means the lungs: crackles, shortness of breath lying flat, cough, and in the worst case pink frothy sputum. Right side means the body: jugular vein distention, enlarged liver, ascites, and swollen ankles. Weight gain and fatigue can show up with either.

What is a hypertensive crisis and what does the nurse do first?

A hypertensive crisis is a systolic pressure over 180 or a diastolic over 120, and it becomes an emergency when there are signs of organ damage like headache, confusion, chest pain, blurred vision or rising creatinine. The nurse puts the client on a monitor, starts frequent blood pressure checks, and expects the pressure to be lowered in steps over hours rather than all at once, because dropping it too fast cuts blood flow to the brain and kidneys.

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