Correct Answers
1. A nurse assesses clients on a cardiac unit. Which client should the
nurse identify as being at greatest risk for the development of left-sided
heart failure?
a. A 36-year-old woman with aortic stenosis
b. A 42-year-old man with pulmonary hypertension
c. A 59-year-old woman who smokes cigarettes daily
d. A 70-year-old man who had a cerebral vascular accident Correct
Answer-ANS: A
Although most people with heart failure will have failure that progresses
from left to right, it is possible to have left-sided failure alone for a short
period. It is also possible to have heart failure that progresses from right
to left. Causes of left ventricular failure include mitral or aortic valve
disease, coronary artery disease, and hypertension. Pulmonary
hypertension and chronic cigarette smoking are risk factors for right
ventricular failure. A cerebral vascular accident does not increase the
risk of heart failure.
2. A nurse assesses a client in an outpatient clinic. Which statement
alerts the nurse to the possibility of left- sided heart failure?
,a. I have been drinking more water than usual.
b. I am awakened by the need to urinate at night.
c. I must stop halfway up the stairs to catch my breath.
d. I have experienced blurred vision on several occasions. Correct
Answer-ANS: C
Clients with left-sided heart failure report weakness or fatigue while
performing normal activities of daily living, as well as difficulty
breathing, or catching their breath. This occurs as fluid moves into the
alveoli. Nocturia is often seen with right-sided heart failure. Thirst and
blurred vision are not related to heart failure.
3. A nurse assesses a client admitted to the cardiac unit. Which
statement by the client alerts the nurse to the possibility of right-sided
heart failure?
a. I sleep with four pillows at night.
b. My shoes fit really tight lately.
c. I wake up coughing every night.
, d. I have trouble catching my breath. Correct Answer-ANS: B
Signs of systemic congestion occur with right-sided heart failure. Fluid
is retained, pressure builds in the venous system, and peripheral edema
develops. Left-sided heart failure symptoms include respiratory
symptoms. Orthopnea, coughing, and difficulty breathing all could be
results of left-sided heart failure.
4. While assessing a client on a cardiac unit, a nurse identifies the
presence of an S3 gallop. Which action should the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit. Correct Answer-ANS: A
The presence of an S3 gallop is an early diastolic filling sound indicative
of increasing left ventricular pressure and left ventricular failure. The
other actions are not warranted.
5. A nurse cares for a client with right-sided heart failure. The client
asks, Why do I need to weigh myself every day? How should the nurse
respond?