NUR 102 FINAL EXAM
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QUESTIONS
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, Page 2 of 48
FINAL EXAM NUR 102
The home care nurse visits a patient with chronic heart failure (HF). Which
assessment findings would indicate acute decompensated heart failure
(ADHF)?
Severe dyspnea and blood-streaked, frothy sputum
Which finding would the nurse recognize as an indication for the use of
dopamine in the care of a patient with heart failure (HF)?
Hypotension and tachycardia
A patient with a recent diagnosis of heart failure (HF) has been prescribed
furosemide. Which outcome would demonstrate medication effectiveness?
Reduced preload
A patient who had bladder surgery 2 days ago develops acute decompensated
heart failure (ADHF) with severe dyspnea. Which action by the nurse would be
indicated first?
Assist the patient to a sitting position with arms on the overbed table.
The nurse is preparing to administer digoxin to a patient with heart failure
(HFLaboratory results include the following findings: sodium 139 mEq/L,
potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is
the priority action by the nurse?
Withhold the dose and report the potassium level.
Which information would the nurse provide to a patient about the use of a
nitroglycerin patch?
Avoid drugs to treat erectile dysfunction.
At a clinic visit, the nurse provides dietary teaching for a patient recently
hospitalized with an exacerbation of chronic heart failure. The nurse
determines that teaching is successful if the patient makes which statement?
"I will limit the amount of milk and cheese in my diet."
An asymptomatic patient with acute decompensated heart failure (ADHF)
suddenly becomes dyspneic. Before dangling the patient on the bedside, what
would the nurse assess first?
Blood pressure
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A patient with a long-standing history of heart failure (HF) recently qualified for
hospice care. Which measure would the nurse now prioritize when providing
care for this patient?
Choose interventions to promote comfort and prevent suffering.
After having a myocardial infarction (MI), a patient has jugular venous
distention (JVD), weight gain, peripheral edema, and a heart rate of 108
beats/min. Which type of heart failure (HF) would the nurse suspect?
Right-sided HF
An older adult patient with chronic heart failure (HF) and atrial fibrillation asks
the nurse why an anticoagulant has been prescribed to continue at home.
Which response would the nurse provide?
"The medication prevents blood clots from forming in your heart."
The nurse prepares to administer digoxin to a patient admitted with influenza
and a history of chronic heart failure (HF). Which result would the nurse review
before giving the medication?
Serum potassium level
The nurse is administering a dose of digoxin to a patient with heart failure
(HF). The nurse would become concerned with the possibility of digitalis
toxicity if the patient reported which symptom?
Loss of appetite
The patient with chronic heart failure (HF) is being discharged from the
hospital. Which information would the nurse emphasize to prevent
progression of the disease to acute decompensated heart failure (ADHF)?
Take medications as prescribed.
A patient admitted with heart failure (HF) is anxious and reports shortness of
breath. Which actions would the nurse take? (Select all that apply.)
Administer prescribed morphine sulfate.
Place patient in a semi-Fowler’s position.
Position patient on left side with head of bed flat.
Instruct patient on the use of relaxation techniques.
Use a calm, reassuring approach while talking to patient.
Administer prescribed morphine sulfate.
Place patient in a semi-Fowler's position.
, Page 4 of 48
Instruct patient on the use of relaxation techniques.
Use a calm, reassuring approach while talking to patient.
The nurse is caring for a 5-year-old child with a congenital heart anomaly
causing chronic cyanosis. when performing the history and physical
examination, what is the nurse least likely to assess?
Obesity from overeating
The nurse is caring for a child after a cardiac catheterization. What is the
nursing priority?
Assess extremity distal to the insertion site for temperature and color.
The nurse is providing discharge instructions to the parent of a 2-month-old
infant who has been prescribed digoxin to be administered every 12 hours
orally. Which instructions should the nurse include in the discharge
instructions? Select three items.
Notify the health care provider or nurse practitioner if more than two consecutive
doses are
If the infant demonstrates poor feeding or vomiting, notify the health care provider or
nurse practitioner.
Always give the medication at regular intervals.
The nurse is caring for an infant with a VSD who has heart failure. The infant
weighs 11 Ib. The medication order reads: spironolactone 5 mg PO every 12
hours. Spironolactone is provided by the pharmacy in a solution of 2.5 mg/1
mL. How many milliliters will the nurse administer? Round to the nearest
whole number.
2 ml
A child on the pediatric unit has morning labo. ratory results of Hgb 10.0, Hct
30.2, WBC 24,000, and platelets 20,000. What is the priority nursing
assessment?
Assess for bruising or bleeding.
A child with hemophilia A fell while riding his bicycle. He was wearing a helmet
and did not lose consciousness. He has a mild abrasion on his knee that is not
oozing. He is complaining of abdominal pain. What is the priority nursing
assessment?
Carefully assess his abdomen.