NU NUR 330 Module 4 (pdf) | 2026/2027 | Nursing Care of Adults and
Older Adults I Q&A | Nursing
1. A nurse is caring for an older adult patient with heart failure. Which of the
following assessment findings is most indicative of worsening fluid overload?
A) Weight loss of 1 kg in 24 hours
B) Jugular venous distention and crackles in the lung bases
C) Decreased blood pressure and tachycardia
D) Increased serum albumin and hematocrit
Correct Answer: Jugular venous distention and crackles in the lung bases
Rationale: Jugular venous distention (JVD) and crackles are classic signs of
fluid overload in heart failure. Weight loss, decreased blood pressure, and
elevated albumin/hematocrit are associated with fluid volume deficit, not
excess.
2. A nurse is providing discharge teaching to a patient with chronic heart
failure. Which of the following statements by the patient indicates an
understanding of dietary management?
A) "I will limit my daily fluid intake to 3 liters."
B) "I will use salt substitutes freely to flavor my food."
C) "I will weigh myself daily and report a weight gain of 2 pounds in 24
hours."
D) "I can eat canned soups as long as I drain the liquid."
Correct Answer: "I will weigh myself daily and report a weight gain of 2
pounds in 24 hours."
Rationale: Daily weight monitoring is essential for early detection of fluid
retention. A weight gain of 2-3 pounds in 24 hours or 5 pounds in a week
,should be reported. Fluid restriction is typically 1.5-2 L/day, salt substitutes
should be used cautiously due to potassium content, and canned soups are
high in sodium.
3. A patient with heart failure is prescribed an angiotensin-converting
enzyme (ACE) inhibitor. The nurse should monitor the patient for which
adverse effect?
A) Hyperkalemia and angioedema
B) Hypokalemia and bradycardia
C) Hyperglycemia and weight gain
D) Hypocalcemia and muscle weakness
Correct Answer: Hyperkalemia and angioedema
Rationale: ACE inhibitors can cause hyperkalemia by reducing aldosterone
secretion and angioedema due to increased bradykinin levels. They do not
typically cause hypokalemia, bradycardia, hyperglycemia, or hypocalcemia.
4. A nurse is assessing a patient who is 3 days post-myocardial infarction.
Which of the following findings requires immediate intervention?
A) Chest pain rated 6/10 that is relieved by nitroglycerin
B) Blood pressure of 100/70 mmHg and heart rate of 90 bpm
C) New-onset crackles in the lung bases and shortness of breath
D) Mild anxiety and fear about returning home
Correct Answer: New-onset crackles in the lung bases and shortness of
breath
Rationale: New-onset crackles and shortness of breath indicate acute
pulmonary edema, a life-threatening complication of heart failure post-MI.
,This requires immediate intervention. Chest pain relieved by nitroglycerin is
expected, mild hypotension and tachycardia may be managed, and anxiety
is a common psychological response.
5. A nurse is teaching a patient about lifestyle modifications to prevent
coronary artery disease. Which of the following recommendations is most
important?
A) "Increase your intake of saturated fats."
B) "Engage in at least 150 minutes of moderate-intensity exercise per week."
C) "Limit your intake of fruits and vegetables."
D) "Avoid monitoring your blood pressure at home."
Correct Answer: "Engage in at least 150 minutes of moderate-intensity
exercise per week."
Rationale: Regular physical activity is a cornerstone of CAD prevention. The
American Heart Association recommends at least 150 minutes of moderate-
intensity exercise per week. Saturated fats should be limited, fruits and
vegetables should be increased, and home blood pressure monitoring is
encouraged.
6. A nurse is assessing a patient with peripheral arterial disease (PAD). Which
of the following findings is most consistent with this condition?
A) Brownish discoloration of the lower legs
B) Thick, dry, and scaly skin on the lower extremities
C) Dependent rubor and pallor on elevation
D) Pitting edema and varicose veins
Correct Answer: Dependent rubor and pallor on elevation
, Rationale: Dependent rubor (redness when legs are dependent) and pallor on
elevation are classic signs of PAD due to inadequate arterial blood flow.
Brownish discoloration, thick scaly skin, edema, and varicose veins are more
characteristic of venous insufficiency.
7. A nurse is providing education to a patient with peripheral arterial disease
about foot care. Which of the following instructions is most appropriate?
A) "Soak your feet in hot water daily to improve circulation."
B) "Use a heating pad to warm your feet if they feel cold."
C) "Inspect your feet daily for cuts, blisters, and redness."
D) "Wear tight-fitting shoes to support your feet."
Correct Answer: "Inspect your feet daily for cuts, blisters, and redness."
Rationale: Daily foot inspection is critical for patients with PAD to detect
injuries early, as poor circulation impairs healing. Hot water and heating pads
can cause burns due to decreased sensation, and tight shoes can impair
circulation and cause pressure ulcers.
8. A nurse is assessing a patient who has just returned from cardiac
catheterization via the femoral artery. Which of the following findings
requires immediate intervention?
A) A pulse distal to the insertion site that is weaker than the contralateral
side
B) A small amount of bloody drainage at the insertion site
C) Complaints of mild back pain
D) An expanding hematoma at the insertion site
Correct Answer: An expanding hematoma at the insertion site
Older Adults I Q&A | Nursing
1. A nurse is caring for an older adult patient with heart failure. Which of the
following assessment findings is most indicative of worsening fluid overload?
A) Weight loss of 1 kg in 24 hours
B) Jugular venous distention and crackles in the lung bases
C) Decreased blood pressure and tachycardia
D) Increased serum albumin and hematocrit
Correct Answer: Jugular venous distention and crackles in the lung bases
Rationale: Jugular venous distention (JVD) and crackles are classic signs of
fluid overload in heart failure. Weight loss, decreased blood pressure, and
elevated albumin/hematocrit are associated with fluid volume deficit, not
excess.
2. A nurse is providing discharge teaching to a patient with chronic heart
failure. Which of the following statements by the patient indicates an
understanding of dietary management?
A) "I will limit my daily fluid intake to 3 liters."
B) "I will use salt substitutes freely to flavor my food."
C) "I will weigh myself daily and report a weight gain of 2 pounds in 24
hours."
D) "I can eat canned soups as long as I drain the liquid."
Correct Answer: "I will weigh myself daily and report a weight gain of 2
pounds in 24 hours."
Rationale: Daily weight monitoring is essential for early detection of fluid
retention. A weight gain of 2-3 pounds in 24 hours or 5 pounds in a week
,should be reported. Fluid restriction is typically 1.5-2 L/day, salt substitutes
should be used cautiously due to potassium content, and canned soups are
high in sodium.
3. A patient with heart failure is prescribed an angiotensin-converting
enzyme (ACE) inhibitor. The nurse should monitor the patient for which
adverse effect?
A) Hyperkalemia and angioedema
B) Hypokalemia and bradycardia
C) Hyperglycemia and weight gain
D) Hypocalcemia and muscle weakness
Correct Answer: Hyperkalemia and angioedema
Rationale: ACE inhibitors can cause hyperkalemia by reducing aldosterone
secretion and angioedema due to increased bradykinin levels. They do not
typically cause hypokalemia, bradycardia, hyperglycemia, or hypocalcemia.
4. A nurse is assessing a patient who is 3 days post-myocardial infarction.
Which of the following findings requires immediate intervention?
A) Chest pain rated 6/10 that is relieved by nitroglycerin
B) Blood pressure of 100/70 mmHg and heart rate of 90 bpm
C) New-onset crackles in the lung bases and shortness of breath
D) Mild anxiety and fear about returning home
Correct Answer: New-onset crackles in the lung bases and shortness of
breath
Rationale: New-onset crackles and shortness of breath indicate acute
pulmonary edema, a life-threatening complication of heart failure post-MI.
,This requires immediate intervention. Chest pain relieved by nitroglycerin is
expected, mild hypotension and tachycardia may be managed, and anxiety
is a common psychological response.
5. A nurse is teaching a patient about lifestyle modifications to prevent
coronary artery disease. Which of the following recommendations is most
important?
A) "Increase your intake of saturated fats."
B) "Engage in at least 150 minutes of moderate-intensity exercise per week."
C) "Limit your intake of fruits and vegetables."
D) "Avoid monitoring your blood pressure at home."
Correct Answer: "Engage in at least 150 minutes of moderate-intensity
exercise per week."
Rationale: Regular physical activity is a cornerstone of CAD prevention. The
American Heart Association recommends at least 150 minutes of moderate-
intensity exercise per week. Saturated fats should be limited, fruits and
vegetables should be increased, and home blood pressure monitoring is
encouraged.
6. A nurse is assessing a patient with peripheral arterial disease (PAD). Which
of the following findings is most consistent with this condition?
A) Brownish discoloration of the lower legs
B) Thick, dry, and scaly skin on the lower extremities
C) Dependent rubor and pallor on elevation
D) Pitting edema and varicose veins
Correct Answer: Dependent rubor and pallor on elevation
, Rationale: Dependent rubor (redness when legs are dependent) and pallor on
elevation are classic signs of PAD due to inadequate arterial blood flow.
Brownish discoloration, thick scaly skin, edema, and varicose veins are more
characteristic of venous insufficiency.
7. A nurse is providing education to a patient with peripheral arterial disease
about foot care. Which of the following instructions is most appropriate?
A) "Soak your feet in hot water daily to improve circulation."
B) "Use a heating pad to warm your feet if they feel cold."
C) "Inspect your feet daily for cuts, blisters, and redness."
D) "Wear tight-fitting shoes to support your feet."
Correct Answer: "Inspect your feet daily for cuts, blisters, and redness."
Rationale: Daily foot inspection is critical for patients with PAD to detect
injuries early, as poor circulation impairs healing. Hot water and heating pads
can cause burns due to decreased sensation, and tight shoes can impair
circulation and cause pressure ulcers.
8. A nurse is assessing a patient who has just returned from cardiac
catheterization via the femoral artery. Which of the following findings
requires immediate intervention?
A) A pulse distal to the insertion site that is weaker than the contralateral
side
B) A small amount of bloody drainage at the insertion site
C) Complaints of mild back pain
D) An expanding hematoma at the insertion site
Correct Answer: An expanding hematoma at the insertion site
