Hinkle 25

Question 1

1. The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem?
   A. Pericarditis
   B. Cardiomyopathy
   C. Pulmonary edema
   D. Right ventricular hypertrophy

Answer 1

C. Pulmonary edema

Question 2

2. The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client’s risk for heart failure?
   A. The client takes furosemide 20 mg/day.
   B. The client’s potassium level is 4.7 mEq/L.
   C. The client is white.
   D. The client’s age is greater than 65.

Answer 2

D. The client’s age is greater than 65.

Question 3

3. The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client’s medical history, which condition is a potential primary cause of the client’s heart failure?
   A. Endocarditis
   B. Pleural effusion
   C. Atherosclerosis
   D. Atrial septal defect

Answer 3

C. Atherosclerosis

Question 4

4. The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize?
   A. Monitoring liver function studies
   B. Blood pressure
   C. Vitamin D intake
   D. Monitoring potassium levels

Answer 4

B. Blood pressure

Question 5

5. The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client’s diagnosis?
   A. Pulmonary edema
   B. Distended neck veins
   C. Dry cough
   D. Orthopnea

Answer 5

B. Distended neck veins

Question 6

6. A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela?
   A. Stroke
   B. Myocardial infarction (MI)
   C. Hemorrhage
   D. Peripheral edema

Answer 6

A. Stroke

Question 7

7. The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information?
   A. Skin turgor
   B. Potassium level
   C. White blood cell count
   D. Peripheral pulses

Answer 7

B. Potassium level

Question 8

8. The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take first?
   A. Check for a carotid pulse.
   B. Apply supplemental oxygen.
   C. Give two full breaths.
   D. Gently shake and shout, “Are you OK?”

Answer 8

D. Gently shake and shout, “Are you OK?”

Question 9

9. A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?
   A. Right-sided heart failure
   B. Acute pulmonary edema
   C. Pneumonia
   D. Cardiogenic shock

Answer 9

B. Acute pulmonary edema

Question 10

10. A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client?
    A. In a high Fowler position
    B. On the left side-lying position
    C. In a flat, supine position
    D. In the Trendelenburg position

Answer 10

A. In a high Fowler position

Question 11

11. The nurse has entered a client’s room and found the client unresponsive and not breathing. What is the nurse’s next appropriate action?
    A. Palpate the client’s carotid pulse.
    B. Illuminate the client’s call light.
    C. Begin performing chest compressions.
    D. Activate the Emergency Response System (ERS).

Answer 11

D. Activate the Emergency Response System (ERS).

Question 12

12. The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?
    A. Monitor and record blood pressure daily.
    B. Monitor and record radial pulses daily.
    C. Monitor weight daily.
    D. Monitor bowel movements.

Answer 12

C. Monitor weight daily.

Question 13

13. The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for?
    A. Jugular vein distention
    B. Right upper quadrant pain
    C. Bibasilar fine crackles
    D. Dependent edema

Answer 13

C. Bibasilar fine crackles

Question 14

14. A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse’s nutritional teaching plan has been effective?
    A. “I will have a ham and cheese sandwich for lunch.”
    B. “I will have a baked potato with broiled chicken for dinner.”
    C. “I will have a tossed salad with cheese and croutons for lunch.”
    D. “I will have chicken noodle soup with crackers and an apple for lunch.”

Answer 14

B. “I will have a baked potato with broiled chicken for dinner.”

Question 15

15. The nurse’s comprehensive assessment of a client who has heart failure includes evaluation of the client’s hepatojugular reflux. What action should the nurse perform during this assessment?
    A. Elevate the client’s head to 90 degrees.
    B. Press the right upper abdomen.
    C. Press above the client’s symphysis pubis.
    D. Lay the client flat in bed.

Answer 15

B. Press the right upper abdomen.

Question 16

16. The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?
    A. The client admitted with acute renal failure
    B. The client admitted following an MI
    C. The client admitted with malignant hypertension
    D. The client admitted following a stroke

Answer 16

B. The client admitted following an MI

Question 17

17. When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
    A. A diastolic blood pressure that is lower during exhalation
    B. A diastolic blood pressure that is higher during inhalation
    C. A systolic blood pressure that is higher during exhalation
    D. A systolic blood pressure that is lower during inhalation

Answer 17

D. A systolic blood pressure that is lower during inhalation

Question 18

18. The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse’s rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm?
    A. Pulseless electrical activity (PEA)
    B. Ventricular fibrillation
    C. Ventricular tachycardia
    D. Asystole

Answer 18

D. Asystole

Question 19

19. The nurse is reviewing a newly admitted client’s electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?
    A. Teach the client deep breathing and coughing exercises.
    B. Administer supplemental oxygen at all times.
    C. Limit the client’s activity level.
    D. Avoid positioning the client supine.

Answer 19

D. Avoid positioning the client supine.

Question 20

20. The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client’s care? Select all that apply.
    A. Improve functional status
    B. Prevent endocarditis.
    C. Extend survival.
    D. Limit physical activity.
    E. Relieve client symptoms.

Answer 20

A. Improve functional status
C. Extend survival.
E. Relieve client symptoms.

Question 21

21. A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment?
    A. Blood pressure
    B. Level of consciousness (LOC)
    C. Nausea
    D. Oxygen saturation

Answer 21

A. Blood pressure

Question 22

22. The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client?
    A. A beta-adrenergic blocker
    B. An antiplatelet aggregator
    C. A calcium channel blocker
    D. A nonsteroidal anti-inflammatory drug (NSAID)

Answer 22

A. A beta-adrenergic blocker

Question 23

23. The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The nurse should anticipate that the prescriber may choose which combination of drugs?
    A. Loop diuretic and antiplatelet aggregator
    B. Loop diuretic and calcium channel blocker
    C. Combination of hydralazine and isosorbide dinitrate
    D. Combination of digoxin and normal saline

Answer 23

C. Combination of hydralazine and isosorbide dinitrate

Question 24

24. A client with a diagnosis of heart failure is started on a beta-blocker. What is the nurse’s priority role during gradual increases in the client’s dose?
    A. Educating the client that symptom relief may not occur for several weeks
    B. Stressing that symptom relief may take up to 4 months to occur
    C. Making adjustments to each day’s dose based on the blood pressure trends
    D. Educating the client about the potential changes in LOC that may result from the drug

Answer 24

A. Educating the client that symptom relief may not occur for several weeks

Question 25

25. The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure? A. An S3 heart sound B. Pleural friction rub C. Faint breath sounds D. A heart murmur

Answer 25

A. An S3 heart sound

Question 26

26. An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified? A. Altered tissue perfusion risk related to arrhythmia B. Excess fluid volume risk related to medication regimen C. Altered breathing pattern risk related to hypoxia D. Falls risk related to hypotension

Answer 26

D. Falls risk related to hypotension

Question 27

27. Cardiopulmonary resuscitation has been initiated on a client who was found unresponsive. When performing chest compressions, the nurse should do which of the following actions? A. Perform at least 100 chest compressions per minute. B. Pause to allow a colleague to provide a breath every 10 compressions. C. Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D. Perform high-quality chest compressions as rapidly as possible.

Answer 27

A. Perform at least 100 chest compressions per minute.

Question 28

28. The nurse is providing client education prior to a client's discharge home after treatment for heart failure. The nurse gives the client a home care checklist as part of the discharge teaching. What should be included on this checklist? A. Know how to recognize and prevent orthostatic hypotension. B. Weigh yourself weekly at a consistent time of day. C. Measure everything you eat and drink until otherwise instructed. D. Limit physical activity to only those tasks that are absolutely necessary.

Answer 28

A. Know how to recognize and prevent orthostatic hypotension.

Question 29

29. The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics? A. Avoid drinking fluids for 2 hours after taking the diuretic. B. Take the diuretic in the morning to avoid interfering with sleep. C. Avoid taking the medication within 2 hours consuming dairy products. D. Take the diuretic only on days when experiencing shortness of breath.

Answer 29

B. Take the diuretic in the morning to avoid interfering with sleep.

Question 30

30. The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A. Facilitate the presence of friends and family whenever possible. B. Teach the client about the harmful effects of anxiety on cardiac function. C. Provide supplemental oxygen, as needed. D. Provide validation of the client's expressions of anxiety. E. Administer benzodiazepines two to three times daily.

Answer 30

A. Facilitate the presence of friends and family whenever possible. C. Provide supplemental oxygen, as needed. D. Provide validation of the client's expressions of anxiety.

Question 31

31. A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. Which action is the nurse's best action? A. Rapidly assess the client's cardiopulmonary status. B. Arrange for an electrocardiogram (ECG). C. Increase the height of the client's bed. D. Manage the client's anxiety.

Answer 31

A. Rapidly assess the client's cardiopulmonary status.

Question 32

32. A cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result? A. Acute pulmonary edema B. Right-sided heart failure C. Right ventricular hypertrophy D. Left-sided heart failure

Answer 32

A. Acute pulmonary edema

Question 33

33. A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? A. Atrial fibrillation B. Infective endocarditis C. Recurrent pneumonia D. Recent surgery

Answer 33

A. Atrial fibrillation

Question 34

34. Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication? A. Pulmonary edema B. Pericardiocentesis C. Cardiac tamponade D. Pericarditis

Answer 34

C. Cardiac tamponade

Question 35

35. The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. Which medical intervention can be performed that may extend the survival of the client? A. Insertion of an implantable cardioverter defibrillator (ICD) B. Insertion of an implantable pacemaker C. Administration of a calcium channel blocker D. Administration of a beta-blocker

Answer 35

A. Insertion of an implantable cardioverter defibrillator (ICD)

Question 36

36. The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply. A. Confusion B. Shortness of breath C. Numbness and tingling in the extremities D. Chest pain E. Bradycardia F. Diuresis

Answer 36

A. Confusion E. Bradycardia

Question 37

37. The nurse is addressing exercise and physical activity during discharge education with a client diagnosed with heart failure. What should the nurse teach this client about exercise? A. "Do not exercise unsupervised." B. "Eventually aim to work up to 30 minutes of exercise each day." C. "Keep exercising but slow down if you get dizzy or short of breath." D. "Start your exercise program with high-impact activities."

Answer 37

B. "Eventually aim to work up to 30 minutes of exercise each day."