Question set B: NGN cardiac items with condensed rationales
A four-column monospaced trend flowsheet for item 3 with five observation rows and light striping, one unremarkable-looking cell carrying the change that matters.
TIMING · 10 MINUTES FOR FIVE ITEMS
1. MATRIX A client is evaluated for a murmur. Sort each finding as indicating aortic stenosis, mitral regurgitation, or neither.
| FINDING | AORTIC STENOSIS | MITRAL REGURGITATION | NEITHER |
|---|---|---|---|
| a. Harsh systolic murmur at the right second intercostal space radiating to the carotids | |||
| b. Blowing holosystolic murmur at the apex radiating toward the axilla | |||
| c. Syncope on exertion | |||
| d. Low-pitched diastolic rumble at the apex with an opening snap | |||
| e. Narrow pulse pressure with a slow rising carotid upstroke | |||
| f. Friction rub that softens when the client sits forward |
2. BOW A 55-year-old arrives with a blood pressure of 214/126 mm Hg, a severe headache, and new blurred vision that began this morning. Select one condition, two actions, and two parameters to monitor. Conditions: hypertensive emergency with target organ injury · hypertensive urgency without organ injury · migraine with aura · acute angle-closure glaucoma. Actions: begin the ordered intravenous antihypertensive with continuous blood pressure monitoring and a gradual reduction of no more than about 25 percent of the mean arterial pressure in the first hour · give the client the oral antihypertensive and recheck in four hours · maintain bed rest with the room quiet and neurologic checks at the ordered interval · encourage ambulation to reduce anxiety. Parameters: level of consciousness and visual acuity · hourly urine output · daily weight · bowel sounds.
3. TREND A client is four hours out from coronary artery bypass grafting. Review the flowsheet and select the finding the nurse reports first.
| 0600 | 0800 | 1000 | 1200 | |
|---|---|---|---|---|
| Mediastinal chest tube output, prior hour | 60 mL | 70 mL | 40 mL | 190 mL |
| Heart rate | 88 | 92 | 96 | 124 |
| Blood pressure | 118/70 | 116/68 | 114/68 | 90/58 |
| Rhythm | Sinus | Sinus | Sinus | Irregularly irregular |
| Temperature | 97.2 F | 97.8 F | 98.4 F | 98.6 F |
Options: rising temperature toward normal · chest tube output of 190 mL in the last hour with a falling blood pressure and a rising heart rate · the new irregularly irregular rhythm · the heart rate of 96 at 1000.
4. DDT Complete the discharge sentence. For a limb with arterial disease, the nurse teaches the client to [1], and for a limb with chronic venous insufficiency, the nurse teaches the client to [2]. [1] keep the legs dependent when night pain wakes them · elevate the legs above heart level for an hour twice daily · apply a knee-high compression stocking each morning. [2] elevate the legs above heart level several times each day · walk until the calf pain forces a stop · soak the leg in hot water each evening.
5. SATA A client with a large pericardial effusion is being monitored. Which findings together suggest tamponade? Select all that apply.
- Blood pressure falling from 124/78 to 86/70 mm Hg.
- Jugular venous distention.
- Heart sounds that are difficult to hear.
- A systolic pressure that drops 14 mm Hg on inspiration.
- Bounding pedal pulses.
- A widening pulse pressure.
Condensed rationales
Item 1 — Answers: a aortic stenosis · b mitral regurgitation · c aortic stenosis · d neither · e aortic stenosis · f neither Stenosis obstructs outflow, so the murmur is systolic, harsh, radiates to the carotids, and produces angina, syncope, and dyspnea with a narrow pressure. Regurgitation at the mitral valve is holosystolic at the apex toward the axilla. Item d is mitral stenosis and item f is pericarditis. → BOOK 08 · P10
Item 2 — Answers: hypertensive emergency with target organ injury · titrated intravenous therapy with gradual reduction, and bed rest with neurologic checks · level of consciousness with visual acuity, and hourly urine output Severe elevation plus new visual change is organ injury, so it is an emergency, not urgency. Oral dosing and ambulation are wrong for the setting. Dropping the pressure too far too fast causes cerebral and renal ischemia. Weight and bowel sounds do not track this organ damage. → BOOK 08 · P9
Item 3 — Answer: chest tube output of 190 mL in the last hour with a falling blood pressure and a rising heart rate Sudden heavy mediastinal drainage with a falling pressure and a climbing rate is surgical bleeding and is reported first. The new atrial fibrillation is real and is reported next, but it is common after bypass and it is not the finding that is currently bleeding out. The temperature is normal rewarming and the rate of 96 is within the trend. → BOOK 08 · P9
Item 4 — Answers: [1] keep the legs dependent when night pain wakes them · [2] elevate the legs above heart level several times each day Arterial flow needs gravity, so the limb hangs down and is never compressed or elevated. Venous return needs the opposite. Walking to the point of pain is a conditioning instruction, not a discharge rule, and hot soaks burn an insensate ischemic limb. → BOOK 08 · P6
Item 5 — Answers: 1, 2, 3, 4 Falling pressure, distended neck veins, and muffled sounds are the classic triad, and a pulsus paradoxus greater than 10 mm Hg supports it. Pulses become weak, not bounding, and the pulse pressure narrows rather than widens. → BOOK 08 · P9
Margin notethe matrix rewards knowing the murmur, not the disease name.
Takeawaynext-generation items score partial credit, so an unattempted cell is a guaranteed loss.