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Accident & Emergency (A&E) II Exam 2026/2027
Edition ||Verified Exam!!!|| ENA & Resuscitation
Council Standards Alignment || MCQ Advanced
Emergency Nursing Competency Assessment
A patient who has chronic heart failure tells the nurse, "I
was fine when I went to bed, but I woke up in the middle of
the night feeling like I was suffocating!" The nurse will
document this assessment finding as
a.orthopnea.
b.pulsus alternans.
c.paroxysmal nocturnal dyspnea.
d.acute bilateral pleural effusion. - Answer-c.paroxysmal
nocturnal dyspnea.
Paroxysmal nocturnal dyspnea is caused by the
reabsorption of fluid from dependent body areas when the
patient is sleeping and is characterized by waking up
suddenly with the feeling of suffocation. Pulsus alternansis
the alternation of strong and weak peripheral pulses
during palpation. Orthopnea indicates that the patient is
unable to lie flat because of dyspnea. Pleural effusions
develop over a longer time period.
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During a visit to a 78-year-old with chronic heart failure,
the home care nurse finds that the patient has ankle
edema, a 2-kg weight gain over the past 2 days, and
complains of "feeling too tired to get out of bed." Based on
these data, the best nursing diagnosis for the patient is
a.activity intolerance related to fatigue.
b.disturbed body image related to weight gain.
c.impaired skin integrity related to ankle edema.
d.impaired gas exchange related to dyspnea on exertion. -
Answer-a.activity intolerance related to fatigue.
The patient's statement supports the diagnosis of activity
intolerance. There are no data to support the other
diagnoses, although the nurse will need to assess for
other patient problems.
The nurse working on the heart failure unit knows that
teaching an older female patient with newly diagnosed
heart failure is effective when the patient states that
a.she will take furosemide (Lasix) every day at bedtime.
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b.the nitroglycerin patch is applied when any chest pain
develops.
c.she will call the clinic if her weight goes from 124 to 128
pounds in a week.
d.an additional pillow can help her sleep if she is feeling
short of breath at night. - Answer-c.she will call the clinic if
her weight goes from 124 to 128 pounds in a week.
Teaching for a patient with heart failure includes
information about the need to weigh daily and notify the
health care provider about an increase of 3 pounds in 2
days or 3 to 5 pounds in a week. Nitroglycerin patches are
used primarily to reduce preload (not to prevent chest
pain) in patients with heart failure and should be used
daily, not on an "as needed" basis. Diuretics should be
taken earlier in the day to avoid nocturia and sleep
disturbance. The patient should call the clinic if increased
orthopnea develops, rather than just compensating by
further elevating the head of the bed.
When teaching the patient with newly diagnosed heart
failure about a 2000-mg sodium diet, the nurse explains
that foods to be restricted include
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a.canned and frozen fruits.
b.fresh or frozen vegetables.
c.eggs and other high-protein foods.
d.milk, yogurt, and other milk products. - Answer-d.milk,
yogurt, and other milk products.
Milk and yogurt naturally contain a significant amount of
sodium, and intake of these should be limited for patients
on a diet that limits sodium to 2000 mg daily. Other milk
products, such as processed cheeses, have very high
levels of sodium and are not appropriate for a 2000-mg
sodium diet. The other foods listed have minimal levels of
sodium and can be eaten without restriction.
The home care nurse visits a patient with chronic heart
failure who is taking digoxin and furosemide. The patient
complains of nausea and vomiting. Which action is most
appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in potassium.
D:Ask the patient to record a weight every morning. -
Answer-B: Notify the health care provider immediately.
Accident & Emergency (A&E) II Exam 2026/2027
Edition ||Verified Exam!!!|| ENA & Resuscitation
Council Standards Alignment || MCQ Advanced
Emergency Nursing Competency Assessment
A patient who has chronic heart failure tells the nurse, "I
was fine when I went to bed, but I woke up in the middle of
the night feeling like I was suffocating!" The nurse will
document this assessment finding as
a.orthopnea.
b.pulsus alternans.
c.paroxysmal nocturnal dyspnea.
d.acute bilateral pleural effusion. - Answer-c.paroxysmal
nocturnal dyspnea.
Paroxysmal nocturnal dyspnea is caused by the
reabsorption of fluid from dependent body areas when the
patient is sleeping and is characterized by waking up
suddenly with the feeling of suffocation. Pulsus alternansis
the alternation of strong and weak peripheral pulses
during palpation. Orthopnea indicates that the patient is
unable to lie flat because of dyspnea. Pleural effusions
develop over a longer time period.
,2|Page
During a visit to a 78-year-old with chronic heart failure,
the home care nurse finds that the patient has ankle
edema, a 2-kg weight gain over the past 2 days, and
complains of "feeling too tired to get out of bed." Based on
these data, the best nursing diagnosis for the patient is
a.activity intolerance related to fatigue.
b.disturbed body image related to weight gain.
c.impaired skin integrity related to ankle edema.
d.impaired gas exchange related to dyspnea on exertion. -
Answer-a.activity intolerance related to fatigue.
The patient's statement supports the diagnosis of activity
intolerance. There are no data to support the other
diagnoses, although the nurse will need to assess for
other patient problems.
The nurse working on the heart failure unit knows that
teaching an older female patient with newly diagnosed
heart failure is effective when the patient states that
a.she will take furosemide (Lasix) every day at bedtime.
,3|Page
b.the nitroglycerin patch is applied when any chest pain
develops.
c.she will call the clinic if her weight goes from 124 to 128
pounds in a week.
d.an additional pillow can help her sleep if she is feeling
short of breath at night. - Answer-c.she will call the clinic if
her weight goes from 124 to 128 pounds in a week.
Teaching for a patient with heart failure includes
information about the need to weigh daily and notify the
health care provider about an increase of 3 pounds in 2
days or 3 to 5 pounds in a week. Nitroglycerin patches are
used primarily to reduce preload (not to prevent chest
pain) in patients with heart failure and should be used
daily, not on an "as needed" basis. Diuretics should be
taken earlier in the day to avoid nocturia and sleep
disturbance. The patient should call the clinic if increased
orthopnea develops, rather than just compensating by
further elevating the head of the bed.
When teaching the patient with newly diagnosed heart
failure about a 2000-mg sodium diet, the nurse explains
that foods to be restricted include
, 4|Page
a.canned and frozen fruits.
b.fresh or frozen vegetables.
c.eggs and other high-protein foods.
d.milk, yogurt, and other milk products. - Answer-d.milk,
yogurt, and other milk products.
Milk and yogurt naturally contain a significant amount of
sodium, and intake of these should be limited for patients
on a diet that limits sodium to 2000 mg daily. Other milk
products, such as processed cheeses, have very high
levels of sodium and are not appropriate for a 2000-mg
sodium diet. The other foods listed have minimal levels of
sodium and can be eaten without restriction.
The home care nurse visits a patient with chronic heart
failure who is taking digoxin and furosemide. The patient
complains of nausea and vomiting. Which action is most
appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in potassium.
D:Ask the patient to record a weight every morning. -
Answer-B: Notify the health care provider immediately.
