HEART FAILURE NCLEX EXAM LATEST VERSION
2023-2024 ACTUAL EXAM 120 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse is caring for a patient with chronic heart failure and atrial fibrillation that takes digoxin and a
thiazide diuretic. Which statement made by the patient indicates that the patient is experiencing a
complication related to the medication?
"My ankles are still slightly swollen."
"I have to urinate a lot after I take those pills!"
"I'm not really hungry for lunch. I feel so nauseated and tired."
"I check my heart rate regularly. It is usually 80-90 beats per minute." - answer-"I'm not really hungry
for lunch. I feel so nauseated and tired."
Drug therapy with digoxin and potassium-losing diuretics (thiazides or loop diuretics) may lead to
hypokalemia. The presence of hypokalemia while the patient is on digoxin may lead to digoxin toxicity.
Signs of early digoxin toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and
visual changes. Slightly swollen ankles are an expected finding with chronic heart failure; frequent
urination is an expected effect of the diuretic. The heart rate of 90 beats/minute is normal.
p. 748
A patient is admitted to the hospital with a diagnosis of acute decompensated heart failure (ACHF). The
primary health care provider prescribes a continuous intravenous infusion of sodium nitroprusside.
What is the priority nursing intervention?
Monitor urinary output.
Monitor blood pressure.
Check serum potassium level.
Assess the skin surrounding the intravenous (IV) site. - answer-monitor BP
A patient newly diagnosed with heart failure is being discharged from the hospital. Which health care
team member frequently works with protocols set up with the patient's health care provider to identify
problems and start interventions?
Physical therapist
Home health nurse
,Occupational therapist
Social services provider - answer-Home health nurses frequently work with protocols set up with the
patient's health care provider. The protocols help the patient to identify problems, such as an increase
in weight or dyspnea, both of which are symptoms of worsening heart failure. Physical therapy or
occupational therapy may not be needed. Social services can assist with obtaining community resources
the patient may need. p. 752
The nurse recognizes that a primary goal for a patient with chronic heart failure is what?
Maximizing cardiac output
Maintaining an ideal body weight
Performing daily aerobic exercises
Maintaining a steady pulse oximetry reading - answer-An increase in cardiac output helps overcome
chronic heart failure, thereby maintaining the blood flow to meet the body's demand. Being overweight
is just one risk factor for chronic heart failure; maintaining ideal body weight may not be a goal for some
patients. Performing daily aerobic exercises may be too strenuous on the heart. There are many risk
factors to consider when determining treatment goals. Pulse oximetry is used to monitor the
effectiveness of oxygen therapy, and achievement of a steady reading is not a practical or primary goal.
p. 746
A patient who underwent cardiac transplantation exhibits signs of acute rejection. The nurse recognizes
that which medication is often used as posttransplantation therapy to prevent this type of response?
Ibuprofen
Metoprolol
Tacrolimus
Acetaminophen - answer-Tacrolimus is a calcineurin that is included in most immunosuppressive
regimens. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID) used to treat pain. Metoprolol is a
beta-blocker that is used to treat hypertension. Acetaminophen is a nonsteroidal antiinflammatory drug
(NSAID) that is used to treat pain and fever. p. 754
A patient with cardiac failure is scheduled to receive sodium nitroprusside. The nurse should monitor
what parameter while administering the drug to the patient?
Blood pressure
Body temperature
Heart rate and pulse rate
,Central venous pressure - answer-Symptomatic hypotension is a major adverse effect of sodium
nitroprusside; therefore, blood pressure is continuously monitored in patients taking sodium
nitroprusside. Body temperature, heart rate, and central venous pressure are not altered due to
administration of this drug. p. 745
The nurse reviews the teaching plan that has been created for a patient with chronic heart failure that is
being discharged from the hospital. The nurse should question which item that is listed on the plan?
Eat small, frequent meals.
Obtain the annual flu vaccine.
Avoid extremes of heat and cold.
Immediately report a weight gain of 5 pounds in 2 days. - answer-The patient should be instructed to
immediately report a weight gain of 3 pounds in 2 days, or 3-5 pounds in a week. Eating small, frequent
meals is a component of the dietary therapy. The patient should be instructed to receive the annual flu
vaccination for health promotion. The patient should be instructed to avoid extremes of heat and cold,
to prevent stress on the heart. P. 751
The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What
is the prioritynursing assessment?
Lung sounds
Facial swelling
Level of anxiety
Intake and output - answer-The priority nursing assessment is auscultation of lung sounds. Excess fluid
volume often leads to pulmonary congestion. ADHF can manifest as pulmonary edema. Facial swelling is
a possible side effect with prescribed renin-angiotensin-aldosterone inhibitors for heart failure. It is
important to assess the patient's anxiety, but it is not the priority. Assessing intake and output is
important for right-sided heart failure.
p. 741
The nurse reviews the laboratory results of a patient with heart failure (HF) who receives a prescription
for digoxin. The nurse decides to withhold the medication based on abnormal findings of what blood
study?
Potassium
Thyroid function tests
White blood cells (WBCs)
, Blood urea nitrogen (B.U.N.) - answer-Low serum potassium enhances the actions of digitalis, causing a
therapeutic dose to reach toxic levels. Similarly, hyperkalemia inhibits the actions of digitalis, resulting in
subtherapeutic dose. Monitor serum potassium levels of all patients taking digitalis. The results of a
B.U.N., WBCs, or thyroid function tests do not affect the nurse's decision to administer or to withhold
digoxin.
p. 748
A patient is diagnosed with left-sided heart failure. The nurse expects what assessment finding?
Orthopnea
Low blood pressure
Pulsating neck veins
Edema in the lower extremities - answer-Orthopnea, difficulty breathing except when sitting or
standing, is a symptom of advanced heart failure, especially left-sided failure. When the heart fails as a
pump, blood backs up into the lungs, causing fluid to leak from the alveolar membrane. As this process
continues, pulmonary edema may develop. Patients may experience hypotension or hypertension,
depending on the severity of the disease. Pulsating neck veins and edema in the lower extremities are
characteristics of right-sided heart failure.
A patient is diagnosed with left ventricular hypertrophy that resulted from untreated hypertension. The
nurse should monitor the patient for symptoms of what condition?
Poor contractility
Less O 2 requirement
Decreased ventricular irritability
Rich coronary arterial circulation - answer-Poor contractility is a complication seen in patients who have
hypertrophy of the cardiac walls. The heart muscle, which undergoes hypertrophy, increases in muscle
mass and cardiac wall thickness, due to overwork and strain. As a result, the hypertrophic heart muscle
exhibits poor contractility over time. Hypertrophic heart muscle is more irritable and, thus, prone to
dysrhythmias. A hypertrophic heart requires more oxygen (O 2) to perform work. Because the tissue in a
hypertrophic heart becomes ischemic more easily, there is poor coronary artery circulation.
p. 740
The nurse recalls that symptoms of right-sided heart failure are caused by what condition?
Decreased preload
Increased cardiac output
2023-2024 ACTUAL EXAM 120 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse is caring for a patient with chronic heart failure and atrial fibrillation that takes digoxin and a
thiazide diuretic. Which statement made by the patient indicates that the patient is experiencing a
complication related to the medication?
"My ankles are still slightly swollen."
"I have to urinate a lot after I take those pills!"
"I'm not really hungry for lunch. I feel so nauseated and tired."
"I check my heart rate regularly. It is usually 80-90 beats per minute." - answer-"I'm not really hungry
for lunch. I feel so nauseated and tired."
Drug therapy with digoxin and potassium-losing diuretics (thiazides or loop diuretics) may lead to
hypokalemia. The presence of hypokalemia while the patient is on digoxin may lead to digoxin toxicity.
Signs of early digoxin toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and
visual changes. Slightly swollen ankles are an expected finding with chronic heart failure; frequent
urination is an expected effect of the diuretic. The heart rate of 90 beats/minute is normal.
p. 748
A patient is admitted to the hospital with a diagnosis of acute decompensated heart failure (ACHF). The
primary health care provider prescribes a continuous intravenous infusion of sodium nitroprusside.
What is the priority nursing intervention?
Monitor urinary output.
Monitor blood pressure.
Check serum potassium level.
Assess the skin surrounding the intravenous (IV) site. - answer-monitor BP
A patient newly diagnosed with heart failure is being discharged from the hospital. Which health care
team member frequently works with protocols set up with the patient's health care provider to identify
problems and start interventions?
Physical therapist
Home health nurse
,Occupational therapist
Social services provider - answer-Home health nurses frequently work with protocols set up with the
patient's health care provider. The protocols help the patient to identify problems, such as an increase
in weight or dyspnea, both of which are symptoms of worsening heart failure. Physical therapy or
occupational therapy may not be needed. Social services can assist with obtaining community resources
the patient may need. p. 752
The nurse recognizes that a primary goal for a patient with chronic heart failure is what?
Maximizing cardiac output
Maintaining an ideal body weight
Performing daily aerobic exercises
Maintaining a steady pulse oximetry reading - answer-An increase in cardiac output helps overcome
chronic heart failure, thereby maintaining the blood flow to meet the body's demand. Being overweight
is just one risk factor for chronic heart failure; maintaining ideal body weight may not be a goal for some
patients. Performing daily aerobic exercises may be too strenuous on the heart. There are many risk
factors to consider when determining treatment goals. Pulse oximetry is used to monitor the
effectiveness of oxygen therapy, and achievement of a steady reading is not a practical or primary goal.
p. 746
A patient who underwent cardiac transplantation exhibits signs of acute rejection. The nurse recognizes
that which medication is often used as posttransplantation therapy to prevent this type of response?
Ibuprofen
Metoprolol
Tacrolimus
Acetaminophen - answer-Tacrolimus is a calcineurin that is included in most immunosuppressive
regimens. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID) used to treat pain. Metoprolol is a
beta-blocker that is used to treat hypertension. Acetaminophen is a nonsteroidal antiinflammatory drug
(NSAID) that is used to treat pain and fever. p. 754
A patient with cardiac failure is scheduled to receive sodium nitroprusside. The nurse should monitor
what parameter while administering the drug to the patient?
Blood pressure
Body temperature
Heart rate and pulse rate
,Central venous pressure - answer-Symptomatic hypotension is a major adverse effect of sodium
nitroprusside; therefore, blood pressure is continuously monitored in patients taking sodium
nitroprusside. Body temperature, heart rate, and central venous pressure are not altered due to
administration of this drug. p. 745
The nurse reviews the teaching plan that has been created for a patient with chronic heart failure that is
being discharged from the hospital. The nurse should question which item that is listed on the plan?
Eat small, frequent meals.
Obtain the annual flu vaccine.
Avoid extremes of heat and cold.
Immediately report a weight gain of 5 pounds in 2 days. - answer-The patient should be instructed to
immediately report a weight gain of 3 pounds in 2 days, or 3-5 pounds in a week. Eating small, frequent
meals is a component of the dietary therapy. The patient should be instructed to receive the annual flu
vaccination for health promotion. The patient should be instructed to avoid extremes of heat and cold,
to prevent stress on the heart. P. 751
The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What
is the prioritynursing assessment?
Lung sounds
Facial swelling
Level of anxiety
Intake and output - answer-The priority nursing assessment is auscultation of lung sounds. Excess fluid
volume often leads to pulmonary congestion. ADHF can manifest as pulmonary edema. Facial swelling is
a possible side effect with prescribed renin-angiotensin-aldosterone inhibitors for heart failure. It is
important to assess the patient's anxiety, but it is not the priority. Assessing intake and output is
important for right-sided heart failure.
p. 741
The nurse reviews the laboratory results of a patient with heart failure (HF) who receives a prescription
for digoxin. The nurse decides to withhold the medication based on abnormal findings of what blood
study?
Potassium
Thyroid function tests
White blood cells (WBCs)
, Blood urea nitrogen (B.U.N.) - answer-Low serum potassium enhances the actions of digitalis, causing a
therapeutic dose to reach toxic levels. Similarly, hyperkalemia inhibits the actions of digitalis, resulting in
subtherapeutic dose. Monitor serum potassium levels of all patients taking digitalis. The results of a
B.U.N., WBCs, or thyroid function tests do not affect the nurse's decision to administer or to withhold
digoxin.
p. 748
A patient is diagnosed with left-sided heart failure. The nurse expects what assessment finding?
Orthopnea
Low blood pressure
Pulsating neck veins
Edema in the lower extremities - answer-Orthopnea, difficulty breathing except when sitting or
standing, is a symptom of advanced heart failure, especially left-sided failure. When the heart fails as a
pump, blood backs up into the lungs, causing fluid to leak from the alveolar membrane. As this process
continues, pulmonary edema may develop. Patients may experience hypotension or hypertension,
depending on the severity of the disease. Pulsating neck veins and edema in the lower extremities are
characteristics of right-sided heart failure.
A patient is diagnosed with left ventricular hypertrophy that resulted from untreated hypertension. The
nurse should monitor the patient for symptoms of what condition?
Poor contractility
Less O 2 requirement
Decreased ventricular irritability
Rich coronary arterial circulation - answer-Poor contractility is a complication seen in patients who have
hypertrophy of the cardiac walls. The heart muscle, which undergoes hypertrophy, increases in muscle
mass and cardiac wall thickness, due to overwork and strain. As a result, the hypertrophic heart muscle
exhibits poor contractility over time. Hypertrophic heart muscle is more irritable and, thus, prone to
dysrhythmias. A hypertrophic heart requires more oxygen (O 2) to perform work. Because the tissue in a
hypertrophic heart becomes ischemic more easily, there is poor coronary artery circulation.
p. 740
The nurse recalls that symptoms of right-sided heart failure are caused by what condition?
Decreased preload
Increased cardiac output
