CHF NCLEX style Questions
Question 1.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which
signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet 2.
Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 9-
and capillary refill time <3 seconds.
ANSWER
1. The client with CHF would exhibit tachycardia, dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status
Question 2.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased
cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? 1. Be
able to ambulate in the hall by date of discharge 2. Have an audible S1 and S2 with no S3 heard by end of shift 3. Turn, cough, and
deep breathe every two hours 4. Have a pulse oximeter reading of 98% by day two of care
ANSWER
2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life
threatening.
Question 3.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should
be included in the plan? Select All that Apply. 1. Notify health-care provider of a weight gain of more than one pound a week. 2.
Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from
the dinner table. 4. Encourage client to monitor urine output for change in color to become dark 5. Discuss the importance of taking
the loop diuretic furosdemide at bedtime
ANSWER
2. The client should not take digoxin if the radial pulse is less than 60.
3. The client should be on a low sodium diet to pre-vent water retention.
Question 4.
The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool
and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead 2. Obtain
a pulse oximetry reading 3. Take the client's vital signs 4. Assist the client into a sitting position
ANSWER
4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion.
Then the nurse would take vital signs and check the pulse oximeter and then sponge the client's forehead.
Question 5.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that medical
treatment has been effective? 1. The client's peripheral pitting edema has gone from a +3 to a +4 2. The client is able to take the
radial pulse accurately 3. The client is able to perform ADLs without dyspnea 4. The client has minimal jugular vein distention
ANSWER
3. Being able to perform activities of daily living without shortness of breath would indicate the client's condition is improving. The client's heart is a more
effective pump and can oxygenate the body better without increasing fluid in the lungs.
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Question 1.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which
signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet 2.
Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 9-
and capillary refill time <3 seconds.
ANSWER
1. The client with CHF would exhibit tachycardia, dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status
Question 2.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased
cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? 1. Be
able to ambulate in the hall by date of discharge 2. Have an audible S1 and S2 with no S3 heard by end of shift 3. Turn, cough, and
deep breathe every two hours 4. Have a pulse oximeter reading of 98% by day two of care
ANSWER
2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life
threatening.
Question 3.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should
be included in the plan? Select All that Apply. 1. Notify health-care provider of a weight gain of more than one pound a week. 2.
Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from
the dinner table. 4. Encourage client to monitor urine output for change in color to become dark 5. Discuss the importance of taking
the loop diuretic furosdemide at bedtime
ANSWER
2. The client should not take digoxin if the radial pulse is less than 60.
3. The client should be on a low sodium diet to pre-vent water retention.
Question 4.
The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool
and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead 2. Obtain
a pulse oximetry reading 3. Take the client's vital signs 4. Assist the client into a sitting position
ANSWER
4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion.
Then the nurse would take vital signs and check the pulse oximeter and then sponge the client's forehead.
Question 5.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that medical
treatment has been effective? 1. The client's peripheral pitting edema has gone from a +3 to a +4 2. The client is able to take the
radial pulse accurately 3. The client is able to perform ADLs without dyspnea 4. The client has minimal jugular vein distention
ANSWER
3. Being able to perform activities of daily living without shortness of breath would indicate the client's condition is improving. The client's heart is a more
effective pump and can oxygenate the body better without increasing fluid in the lungs.
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