UNFOLDING REASONING CASE
STUDY HEART FAILURE JOANN
SMITH 72 YEARS BANK UPDATED
QUESTIONS ANSWERS GRADED
⩥ Based on the client's history and assessment, the nurse will be most
concerned about which complication?
1.Pulmonary edema 2.Cor pulmonale 3.Pneumonia 4.Pulmonary
embolus. Answer: 1.
Pulmonary edema
⩥ Which action will the nurse take next?
1.Activate the hospital's Rapid Response Team (RRT). 2.Switch to a
nonrebreather mask at a O2 flow rate of 15 L/min. 3.Assist the client to
cough and deep breathe. 4.Administer the pre. Answer: 2.
Switch to a nonrebreather mask at a O2 flow rate of 15 L/min
⩥ What additional assessment data are most important to obtain at this
time?
1.Skin color and capillary refill 2.Orientation and pupil reaction to light
3.Heart sounds and point of maximum impulse 4.Blood pressure and
apical pulse Answer: 4.
Blood pressure and apical pulse
, ⩥ Ms. C's blood pressure is 98/52 mm Hg, and her apical pulse is 116
beats/min. The cardiac monitor shows sinus tachycardia at a rate of 110
to 120 beats/min. Which action prescribed by the health care provider
(HCP) will the nurse implement first?
1.Give enalapril 2.5 mg PO. 2.Administer furosemide 100 mg IV.
3.Obtain a blood potassium level. 4.Insert a no. 16 French Foley
catheter. Answer: 3.
Obtain a blood potassium level.
⩥ Which prescribed action is best to assign to the experienced
LPN/LVN who is assisting with the client's care?
1.Give enalapril 2.5 mg PO. 2.Administer furosemide 100 mg IV.
3.Obtain a blood potassium level. 4.Insert a no. 16 French Foley
catheter. Answer: 4.
Insert a no. 16 French Foley catheter.
⩥ The nurse administers morphine sulfate 2 mg IV to Ms. C. A new RN
graduate who has just started in the ICU asks why morphine is
prescribed for this client. What is the best response?
1."To help prevent chest discomfort." 2."To slow Ms. C's respiratory
rate." 3."To lower Ms. C's anxiety level." 4."To decrease venous return
to the heart." Answer: 4.
"To decrease venous return to the heart."
STUDY HEART FAILURE JOANN
SMITH 72 YEARS BANK UPDATED
QUESTIONS ANSWERS GRADED
⩥ Based on the client's history and assessment, the nurse will be most
concerned about which complication?
1.Pulmonary edema 2.Cor pulmonale 3.Pneumonia 4.Pulmonary
embolus. Answer: 1.
Pulmonary edema
⩥ Which action will the nurse take next?
1.Activate the hospital's Rapid Response Team (RRT). 2.Switch to a
nonrebreather mask at a O2 flow rate of 15 L/min. 3.Assist the client to
cough and deep breathe. 4.Administer the pre. Answer: 2.
Switch to a nonrebreather mask at a O2 flow rate of 15 L/min
⩥ What additional assessment data are most important to obtain at this
time?
1.Skin color and capillary refill 2.Orientation and pupil reaction to light
3.Heart sounds and point of maximum impulse 4.Blood pressure and
apical pulse Answer: 4.
Blood pressure and apical pulse
, ⩥ Ms. C's blood pressure is 98/52 mm Hg, and her apical pulse is 116
beats/min. The cardiac monitor shows sinus tachycardia at a rate of 110
to 120 beats/min. Which action prescribed by the health care provider
(HCP) will the nurse implement first?
1.Give enalapril 2.5 mg PO. 2.Administer furosemide 100 mg IV.
3.Obtain a blood potassium level. 4.Insert a no. 16 French Foley
catheter. Answer: 3.
Obtain a blood potassium level.
⩥ Which prescribed action is best to assign to the experienced
LPN/LVN who is assisting with the client's care?
1.Give enalapril 2.5 mg PO. 2.Administer furosemide 100 mg IV.
3.Obtain a blood potassium level. 4.Insert a no. 16 French Foley
catheter. Answer: 4.
Insert a no. 16 French Foley catheter.
⩥ The nurse administers morphine sulfate 2 mg IV to Ms. C. A new RN
graduate who has just started in the ICU asks why morphine is
prescribed for this client. What is the best response?
1."To help prevent chest discomfort." 2."To slow Ms. C's respiratory
rate." 3."To lower Ms. C's anxiety level." 4."To decrease venous return
to the heart." Answer: 4.
"To decrease venous return to the heart."
