NUR 120 (MED/SURG - Test 4) NCLEX STYLE PRACTICE
Questions with Correct Answers (Grade A+)
Question 1: The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes
during the night frightened and short of breath. Based on this data, what is the client experiencing?
A) Cardiomyopathy
B) Paroxysmal nocturnal dyspnea
C) High-output failure
D) Multisystem heart failure **P-16**
Answer: B (Paroxysmal nocturnal dyspnea)
Question 2: The nurse is planning care for several clients. Which client should the nurse identify as
being at greatest risk of developing heart failure?
A) A 69-year-old African American male with hypertension
B) A 50-year-old African American female who smokes
C) A 75-year-old Caucasian male who is overweight
D) A 52-year-old Caucasian female with asthma **P-16**
Answer: A (A 69-year-old African American male with hypertension)
Question 3: The nurse is caring for a child with congestive heart failure (CHF). Which clinical
manifestations does the nurse anticipate when assessing this child? (Select all that apply)
A) Excessive sweating
B) Hypertension
C) Bradycardia
D) Difficulty breathing
E) Increased appetite **P-16**
Answer: A & D (Excessive sweating) (Difficulty breathing)
Question 4: During an assessment, a client with left-sided congestive heart failure (CHF) and severe
shortness of breath tells the nurse about not having enough money to purchase medications. What
nursing diagnosis is of the greatest initial importance when planning care?
A) Excess Fluid Volume
B) Ineffective Health Management
C) Noncompliance
D) Activity Intolerance **P-16**
Answer: A (Excess Fluid Volume)
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, Question 5: The nurse is assessing a client being treated for congestive heart failure (CHF). Which
physical findings would indicate that the client's condition is not improving? (Select all that apply)
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6°F (37°C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus **P-16**
Answer: A & D (Urine output 160 ml over 8 hours) (Wheezing of breath sounds in all lobes)
Question 6: The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position
is most appropriate for this client?
A) Reclining with 3 pillows under head
B) Lying on the left side with 1 pillow under head
C) Lying supine with 1 pillow under head
D) Lying in the Sims position with 2 pillows under head **P-16**
Answer: A (Reclining with 3 pillows under head)
Question 7: The nurse is performing an assessment of a client. Which should the nurse recognize as a
noncardiac risk factor for heart failure?
A) Myocardial Infarction
B) Hypertension
C) Hyperthyroidism
D) Congenital Heart Defects **P-16**
Answer: C (Hyperthyroidism)
Question 8: When planning care for this client, which does the nurse understand about systolic heart
failure?
A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial
system
B) Results when the heart cannot completely relax in diastole, disrupting normal filling
C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload
D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired
relaxation of the heart muscle **P-16**
Answer: A (Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into
the arterial system)
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Questions with Correct Answers (Grade A+)
Question 1: The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes
during the night frightened and short of breath. Based on this data, what is the client experiencing?
A) Cardiomyopathy
B) Paroxysmal nocturnal dyspnea
C) High-output failure
D) Multisystem heart failure **P-16**
Answer: B (Paroxysmal nocturnal dyspnea)
Question 2: The nurse is planning care for several clients. Which client should the nurse identify as
being at greatest risk of developing heart failure?
A) A 69-year-old African American male with hypertension
B) A 50-year-old African American female who smokes
C) A 75-year-old Caucasian male who is overweight
D) A 52-year-old Caucasian female with asthma **P-16**
Answer: A (A 69-year-old African American male with hypertension)
Question 3: The nurse is caring for a child with congestive heart failure (CHF). Which clinical
manifestations does the nurse anticipate when assessing this child? (Select all that apply)
A) Excessive sweating
B) Hypertension
C) Bradycardia
D) Difficulty breathing
E) Increased appetite **P-16**
Answer: A & D (Excessive sweating) (Difficulty breathing)
Question 4: During an assessment, a client with left-sided congestive heart failure (CHF) and severe
shortness of breath tells the nurse about not having enough money to purchase medications. What
nursing diagnosis is of the greatest initial importance when planning care?
A) Excess Fluid Volume
B) Ineffective Health Management
C) Noncompliance
D) Activity Intolerance **P-16**
Answer: A (Excess Fluid Volume)
Page 1
, Question 5: The nurse is assessing a client being treated for congestive heart failure (CHF). Which
physical findings would indicate that the client's condition is not improving? (Select all that apply)
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6°F (37°C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus **P-16**
Answer: A & D (Urine output 160 ml over 8 hours) (Wheezing of breath sounds in all lobes)
Question 6: The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position
is most appropriate for this client?
A) Reclining with 3 pillows under head
B) Lying on the left side with 1 pillow under head
C) Lying supine with 1 pillow under head
D) Lying in the Sims position with 2 pillows under head **P-16**
Answer: A (Reclining with 3 pillows under head)
Question 7: The nurse is performing an assessment of a client. Which should the nurse recognize as a
noncardiac risk factor for heart failure?
A) Myocardial Infarction
B) Hypertension
C) Hyperthyroidism
D) Congenital Heart Defects **P-16**
Answer: C (Hyperthyroidism)
Question 8: When planning care for this client, which does the nurse understand about systolic heart
failure?
A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial
system
B) Results when the heart cannot completely relax in diastole, disrupting normal filling
C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload
D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired
relaxation of the heart muscle **P-16**
Answer: A (Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into
the arterial system)
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