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RNNCLEX EXAM2025 VERSION WITH NGN|ALL160 QUESTIONS WITH CORRECT ANSWERS | ALREADY GRADEDA+| LATEST UPDATE 1. The intensive care unit (ICU) charge nurse will determine that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse A) Positions the zero-reference stopcock line level with the phlebostatic axis. B) Balances and calibrates the hemodynamic monitoring equipment every hour. C) Rechecks the location of the phlebostatic axis when changing the patient's position. D) Ensures that the patient is lying supine with the head of the bed flat for all readings. ANSWER>>A) Positions the zero-reference stopcock line level with the phlebostatic axis. 2. The mixed venous oxygen saturation/central venous oxygen saturation (SvO2/ScvO2) ratio is expected to decrease in patients with: A) Hypethermia B) Anemia C) Balanced oxygen supply and demand D) Sepsis- ANSWER>>B) Anemia
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Pressure (PAWP).
B) More than 100 beat/min. C) Less than 60 beat/min. D) Between 50 and 70 beat/min. - ANSWER>>C) Less than 60 beat/min.
D) It is very important to take nitrates before exercising. - ANSWER>>A) It is very important that you stop smoking cigarettes.
D) respiritory acidosis in apatient with COPD because of alveolar hyperventilation and increased PaO2 levels. - ANSWER>>C) signs of cardiovascular insufficiency because pressure in the chest impeds venous return In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include which of the following (select all)? A) diffuse involvement of plaque formation in coronary veins. B) abnormal levels of cholestrol, particularly LDLs C) accumulation of ipid and fibrous tissue within the coronary arteries D) development of angia due to decreased blood supply to the heart muscle E) chronic vasoconstriction of coronary arteries leading to permanent vasospasm - ANSWER>>B) abnormal levels of cholestrol, particularly LDLs C) accumulation of ipid and fibrous tissue within the coronary arteries D) development of angia due to decreased blood supply to the heart muscle After teaching ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says,? A) I would like to add weight lifting to my exercise program B) I can keep my blood pressure normal with medication C) I can change my diet to decrease my intake of saturated fats D) I will change my lifestyle to reduce activities that increase my stress - ANSWER>>A) I would like to add weight lifting to my exercise program A hospitalized patient with a history of chronic stable angian tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia? A) will always progress to MI B) will be relieved by rest, nitro, or both C) indicates that irreversible myocardial damage is occurring D) is frequently associated with vomiting and extreme fatigue - ANSWER>>B) will be relieved by rest, nitro, or both The nurse is caring for a patient who is two days post MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which of the following actions would be a priority? A) Notify the physician STAT and obtain a 12 lead ECG B) Obtain vital signs and ausculatate for a pericardial friction rub C) Apply high-flow oxygen by face mask and auscultate breath sounds D) Medicate the patient with PRN anagesic and reevaluate in 30 minutes. - ANSWER>>B) Obtain vital signs and ausculatate for a pericardial friction rub A patient is admitted to the CCU with a diagnosis of unstable angina. Which of the following medications would the nurse expect the patient to receive (select all)? A) antiplatlet therapy B) fibrinolytic therapy C) B-adrenergic blockers D) prophylactic antibiotics E) intravenous nitroglycerin - ANSWER>>A) antiplatlet therapy C) B-adrenergic blockers E) intravenous nitroglycerin A patient is recovering from an uncomplicated MI. Which of the following rehabilitation guidelines is a priority to include in the teaching plan? A) Refrain from sexual activity for a minimum of 3 weeks B) Plan a diet program that aims for a 1 to 2 pound weight loss per week C) Begin an exercise program that aims for at least five 30 minute sessions per week D) Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity - ANSWER>>C) Begin an exercise program that aims for at least five 30 minute sessions per week The most common finding in individuals at risk for sudden cardiac death is? A) aortic valve disease B) mitral valve disease C) left ventricular dysfunction D) atherosclerotic heart disease - ANSWER>>C) left ventricular dysfunction The nurse recognizes that primary manifestaions of systolic failure include?
A) decreased EF and increased PAWP B) decreased PAWP and increased EF C) decreased pulmonary hypertension associated with normal EF D) decreased afterload and decreased left ventricular end-diastolic pressure - ANSWER>>A) decreased EF and increased PAWP A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is? A) ventricular dilation B) ventricualr hypertrophy C) neurohormonal response D) sympathetic nervous system activation - ANSWER>>C) neurohormonal response A drug used in the management of a patient with ADHF and pulmonary edema that will decrease both preload and afterload and provide releif of anxiety is? A) amrinone B) furosemide C) dobutamine D) morphine sulfate - ANSWER>>D) morphine sulfate A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, the nurse needs to? A) monitor serum potassium levels B) keep an accurate measure of intake and output C) teach the patient about dietary restriction of potassium D) withhold digitalis and notify health care provider if heart rate is irregular - ANSWER>>A) monitor serum potassium levels Patients with heart transplantation are at risk for which of the following complications in the first year after transplantation (select all)? A) cancer B) infection C) rejection D) vasculopathy E) sudden cardiac death - ANSWER>>B) infection C) rejection E) sudden cardiac death A patient admitted with ACS has continuous ECG monitoring. An examination of the rhythum strip reveals the following characteristics: atrial rate - 74 and regular; ventricular rate - 62 and irregular; P wave - normal shape; PR interval - lengthens progressively until a P wave is not conducted; QRS - normal shape. The priority nursing intervention would involve? A) performing synchronized cardioversion B) administering epinephrine 1 mg IV push C) observing for symptoms of hypotension or angina D) preparing the patient for a transcutaneous pacemaker - ANSWER>>C) observing for symptoms of hypotension or angina The nurse is monitoring the ECG of a patient admitted with ACS. Which of the following ECG characteristics would be most suggestive of ischemia? A) Sinus rhythm with a pathologic Q wave B) Sinus thythm with an elevated ST segment C) Sinus rhythm with a depressed ST segment D) Sinus rhythm with premature artial contractions - ANSWER>>C) Sinus rhythm with a depressed ST segment The ECG monitor of a patient in the cardiac care unit following an MI indicates ventricular bigeminy with a rate of 50 beats/minute. The nurse would anticipate? A) performing defibrillation B) treatment with IV lidocaine C) insertion of a temporary, transvenous pacemaker D) assessing the patient's response to the dysrhythmia - ANSWER>>D) assessing the patient's response to the dysrhythmia The prepares a patient for synchronized cardioversion knowing that cardioversion differs from
should discuss the possibilty of? A) valvular heart disease B) pulmonary hypertension C) superior vena cava syndrome D) hypertrophy of the right ventricle - ANSWER>>A) valvular heart disease Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever? A) Administration of antobiotics as ordered B) Management of pain with opioid analgesics C) Encouragement of fluid intake for hydration D) Performance of frequent, active range-of-motion exercises. - ANSWER>>A) Administration of antobiotics as ordered Which clinical finding would most likley indicate decreased cardiac output in a patient with aortic valve regurgitation? A) reduction in peripheral edema and weight B) carotid venous distention and new onset atrial fibrillation C) significant pulses paradoxus and diminished peripheral pulses D) shortness of breath on minimal exertion and a diastolic murmur - ANSWER>>D) shortness of breath on minimal exertion and a diastolic murmur A patient is diagnosed with mitral stenosis and new-onset artial fibrillation. Which interventions could the nurse delegate to nursing assitive personal (select all) A) obtain and record daily weight B) determine apical-radial pulse rate C) observe for overt signs of bleeding D) obtain and record vital signs, including pulse oximetery E) teach the patient how to purchase a medic alert bracelet - ANSWER>>A) obtain and record daily weight C) observe for overt signs of bleeding D) obtain and record vital signs, including pulse oximetery Which of the following diagnositic study best differentiates the various types of cardiomyopathy? A) Echocardiography B) Arterial blood gases C) Cardiac catherization D) Endomyocardial biopsy - ANSWER>>A) Echocardiography The nurse is caring for a patient newly admitted with heart failure secondary to dilated cardiomyopathy. Which of the following interventions would be a priority? A) encourage caregivers to learn CPR B) consider a consultaion with hospice for palliative care C) moniter the patient's response to prescribed medications D) arrange for the patient to enter a cardiac rehabillitation program - ANSWER>>C) moniter the patient's response to prescribed medications A 50 year old woman weighs 85 kg and has a history of cigarette smoking, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are? A) weight and diet B) activity level and diet C) cigarette smoking and high blood pressure D) sedentary lifestyle and high blood pressure - ANSWER>>C) cigarette smoking and high blood pressure A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which of the following signs and symptoms would suggest that his aneurysm has ruptured? A) sudden shortness of breath and hemoptysis B) sudden, severe low backpain and brusing along his flank C) gradually increasing substernal chest pain and diaphoresis D) sudden, patchy blue mottling on feet and toes and rest pain - ANSWER>>B) sudden, severe low backpain and brusing along his flank
Priotiry nursing measures after an abdominal aortic aneurysm repair include? A) assessment of cranical nerves and mental status. B) administration of IV heparin and monitoring aPTT C) administration of IV fluids and monitoring kidney function D) elevation of the legs and application of graduated compression stockings - ANSWER>>C) administration of IV fluids and monitoring kidney function The first priority of collaborative care of a patient with a suspected acute aortic dissection is to? A) reduce anxiety B) control blood pressure C) monitor for chest pain D) increase myocardial contractility - ANSWER>>B) control blood pressure Rest pain is a manifestation of PAD that occurs due to a chronic? A) vasospasm of small cutaneous arteries in the feet B) increase in retrograde venous blood flow in the legs C) decrease in arterial blood flow to the nerves of the feet D) decrease in arterial blood flow to the leg muscles during exercise - ANSWER>>C) decrease in arterial blood flow to the nerves of the feet A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to? A) elevate the leg to promote venous return B) start anticoagulant therapy with IV heparin C) notify the physician of the change in peripheral perfusion D) place the bed in reverse trendelenburg to promote perfusion - ANSWER>>C) notify the physician of the change in peripheral perfusion Which clinical manifestations are seen in both patients with Buerger's diesease and Raynaud's phenomenon (select all)? A) Intermittent fevers B) sensitivity to cold temperatures C) gangrenous ulcers on fingertips D) color changes of fingers and toes E) episodes of superficial vein thrombosis - ANSWER>>B) sensitivity to cold temperatures C) gangrenous ulcers on fingertips D) color changes of fingers and toes The patient at highest risk for venous thromboembolism (VTE) is? A) a 62 year old man with spider veins who is having arthroscopic knee surgery B) a 32 year old woman who smokes, takes oral contraceptives, and is planning a trip to Europe C) a 26 year old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor D) an active 72 year old man at home recovering from a TURP for benign prostatic hyperplasia - ANSWER>>B) a 32 year old woman who smokes, takes oral contraceptives, and is planning a trip to Europe Which are probable clinical findings in a person with an acute VTE (select all)? A) pallor and coolness of foot and calf B) Mild to moderate calf pain and tenderness C) grossly diminished or absent pedal pulses D) unilateral edema and induration of the thigh E) palpable cord along a superficial varicose vein - ANSWER>>B) Mild to moderate calf pain and tenderness D) unilateral edema and induration of the thigh The recommended treatment for an initial VTE in an otherwise healthy person with no significant co-morbidities would include A) IV agratoban (Acova) as an inpatient B) IV unfractionated heparin as an inpatient C) subcutaneous infractionated heparin as an outpatient D) subcutaneous low-molecular-weight heparin as an outpatient - ANSWER>>D) subcutaneous low-molecular-weight heparin as an outpatient A key aspect of teaching for the patient on anticoagulant therapy includes which instructions?