NUR 2502 / NUR2502 Final Exam
(Latest ):
Multidimensional Care III / MDC 3 -
Rasmussen
1. A patient with a history of heart failure is admitted with acute
decompensated heart failure. The nurse assesses jugular venous distention, 3+
pitting edema in the lower extremities, and crackles in the lung bases. Which of
the following is the priority nursing action?
A. Administer a loop diuretic as ordered
B. Place the patient in a high-Fowler's position
C. Begin strict intake and output monitoring
D. Weigh the patient to establish a baseline
Correct Answer: B
Rationale: The priority is to manage the patient's symptoms. Placing the patient in a
high-Fowler's position uses gravity to reduce preload and improve lung expansion,
which alleviates dyspnea and crackles. While diuretics are the definitive treatment,
positioning is an immediate, independent nursing action to support ventilation.
2. How often should a patient with heart failure weigh themselves?
A. Weekly
B. Monthly
,C. Daily
D. Hourly
Correct Answer: C
Rationale: Patients with heart failure should weigh themselves daily at the same
time each day, using the same scale, and with similar clothing. A weight gain of 2-3
pounds in 24 hours or 5 pounds in a week indicates fluid retention and should be
reported to the healthcare provider.
3. What blood test is used to detect heart failure?
A. Troponin
B. Complete blood count (CBC)
C. B-type natriuretic peptide (BNP)
D. Arterial blood gases (ABGs)
Correct Answer: C
Rationale: BNP is a hormone secreted by the ventricles in response to increased
pressure and volume overload. Elevated BNP levels are a sensitive and specific
marker for heart failure and can also help differentiate heart failure from other
causes of dyspnea.
4. What diagnostic test is the gold standard to determine if a patient has heart
failure?
A. Echocardiogram (ECHO)
B. MRI
,C. Chest X-ray
D. Ultrasound
Correct Answer: A
Rationale: An echocardiogram is the gold standard for diagnosing heart failure. It
provides information about ejection fraction, ventricular size and function, and
valvular abnormalities, which are essential for determining the type and severity of
heart failure.
5. Which of the following are risk factors that can lead to heart failure? (Select
all that apply)
A. Lifestyle factors
B. Hypertension
C. Smoking
D. Diabetes
Correct Answer: A, B, C, D
Rationale: All of these are risk factors for heart failure. Lifestyle factors (sedentary
behavior, poor diet), hypertension (increases afterload), smoking (damages
vasculature), and diabetes (contributes to microvascular disease and
cardiomyopathy) all increase the risk of developing heart failure.
6. What can predispose a patient to mitral stenosis?
A. Rheumatic fever
B. Age
, C. Connective tissue disorder
D. Infective endocarditis
Correct Answer: A
Rationale: Rheumatic fever is the most common cause of mitral stenosis. The
inflammatory process from rheumatic fever causes scarring and fusion of the mitral
valve leaflets, leading to narrowing of the valve orifice.
7. On auscultation, what is the classic heart sound the nurse expects to hear in
a patient with mitral valve stenosis?
A. A high-pitched, blowing systolic murmur at the apex
B. A low-pitched, rumbling diastolic murmur at the apex
C. A mid-systolic click followed by a late systolic murmur
D. A harsh, crescendo-decrescendo murmur at the right sternal border
Correct Answer: B
Rationale: Mitral valve stenosis, a narrowing of the mitral valve orifice, impedes
blood flow from the left atrium to the left ventricle during diastole, creating a low-
pitched, rumbling diastolic murmur best heard at the apex of the heart.
8. Which of the following is NOT a symptom of mitral valve stenosis?
A. Fatigue
B. Hypertension
C. Dyspnea on exertion
D. Pink frothy sputum
(Latest ):
Multidimensional Care III / MDC 3 -
Rasmussen
1. A patient with a history of heart failure is admitted with acute
decompensated heart failure. The nurse assesses jugular venous distention, 3+
pitting edema in the lower extremities, and crackles in the lung bases. Which of
the following is the priority nursing action?
A. Administer a loop diuretic as ordered
B. Place the patient in a high-Fowler's position
C. Begin strict intake and output monitoring
D. Weigh the patient to establish a baseline
Correct Answer: B
Rationale: The priority is to manage the patient's symptoms. Placing the patient in a
high-Fowler's position uses gravity to reduce preload and improve lung expansion,
which alleviates dyspnea and crackles. While diuretics are the definitive treatment,
positioning is an immediate, independent nursing action to support ventilation.
2. How often should a patient with heart failure weigh themselves?
A. Weekly
B. Monthly
,C. Daily
D. Hourly
Correct Answer: C
Rationale: Patients with heart failure should weigh themselves daily at the same
time each day, using the same scale, and with similar clothing. A weight gain of 2-3
pounds in 24 hours or 5 pounds in a week indicates fluid retention and should be
reported to the healthcare provider.
3. What blood test is used to detect heart failure?
A. Troponin
B. Complete blood count (CBC)
C. B-type natriuretic peptide (BNP)
D. Arterial blood gases (ABGs)
Correct Answer: C
Rationale: BNP is a hormone secreted by the ventricles in response to increased
pressure and volume overload. Elevated BNP levels are a sensitive and specific
marker for heart failure and can also help differentiate heart failure from other
causes of dyspnea.
4. What diagnostic test is the gold standard to determine if a patient has heart
failure?
A. Echocardiogram (ECHO)
B. MRI
,C. Chest X-ray
D. Ultrasound
Correct Answer: A
Rationale: An echocardiogram is the gold standard for diagnosing heart failure. It
provides information about ejection fraction, ventricular size and function, and
valvular abnormalities, which are essential for determining the type and severity of
heart failure.
5. Which of the following are risk factors that can lead to heart failure? (Select
all that apply)
A. Lifestyle factors
B. Hypertension
C. Smoking
D. Diabetes
Correct Answer: A, B, C, D
Rationale: All of these are risk factors for heart failure. Lifestyle factors (sedentary
behavior, poor diet), hypertension (increases afterload), smoking (damages
vasculature), and diabetes (contributes to microvascular disease and
cardiomyopathy) all increase the risk of developing heart failure.
6. What can predispose a patient to mitral stenosis?
A. Rheumatic fever
B. Age
, C. Connective tissue disorder
D. Infective endocarditis
Correct Answer: A
Rationale: Rheumatic fever is the most common cause of mitral stenosis. The
inflammatory process from rheumatic fever causes scarring and fusion of the mitral
valve leaflets, leading to narrowing of the valve orifice.
7. On auscultation, what is the classic heart sound the nurse expects to hear in
a patient with mitral valve stenosis?
A. A high-pitched, blowing systolic murmur at the apex
B. A low-pitched, rumbling diastolic murmur at the apex
C. A mid-systolic click followed by a late systolic murmur
D. A harsh, crescendo-decrescendo murmur at the right sternal border
Correct Answer: B
Rationale: Mitral valve stenosis, a narrowing of the mitral valve orifice, impedes
blood flow from the left atrium to the left ventricle during diastole, creating a low-
pitched, rumbling diastolic murmur best heard at the apex of the heart.
8. Which of the following is NOT a symptom of mitral valve stenosis?
A. Fatigue
B. Hypertension
C. Dyspnea on exertion
D. Pink frothy sputum
