A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
1.The home care nurse visits a patient with chronic heart failure who is
taking digoxin and furosemide. The patient complains of nausea and
vomiting. Which action is most appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in
potassium.
D:Ask the patient to record a weight every morning.: B: Notify the health
care provider immediately.
2.A patient with left-sided heart failure is prescribed oxygen at 4 L/min per
nasal cannula, furosemide, spironolactone, and enalapril. Which
assessment should the nurse complete to best evaluate the patient's
response to these drugs?
A: Observe skin turgor
B: Auscultate lung sounds
C: Measure blood pressure
D: Review intake and output: B: Auscultate lung sounds
Left = Lungs
3.While assessing a 68-year-old with ascites, the nurse also notes jugular
venous distention (JVD) with the head of the patient's bed elevated 45
degrees.
The nurse knows this finding indicates
a.decreased fluid volume.
b.jugular vein atherosclerosis.
c.increased right atrial pressure.
d.incompetent jugular vein valves.: c.increased right atrial pressure.
The jugular veins empty into the superior vena cava and then into the
right atrium, so JVD with the patient sitting at a 45-degree angle reflects
increased right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not
decreased fluid volume. JVD is not caused by incompetent jugular vein
valves or atherosclerosis.
4.The nurse is caring for a patient who is receiving IV furosemide (Lasix)
and morphine for the treatment of acute decompensated heart failure
(ADHF) with severe orthopnea. Which clinical finding is the best indicator
that the treatment has been effective?
, A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
a. Weight loss of 2 pounds in 24 hours
, A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
b. Hourly urine output greater than 60 mL
c.Reduction in patient complaints of chest
pain
d.Reduced dyspnea with the head of bed at 30 degrees: d.Reduced
dyspnea with the head of bed at 30 degrees
Because the patient's major clinical manifestation of ADHF is orthopnea
(caused by the presence of fluid in the alveoli), the best indicator that
the medications are effective is a decrease in dyspnea with the head of
the bed at 30 degrees. The other assessment data also may indicate
that diuresis or improvement in cardiac output has occurred, but are
not as specific to evaluating this patient's response.
5.Which topic will the nurse plan to include in discharge teaching for a
patient with systolic heart failure and an ejection fraction of 33%?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Benefits and side effects of angiotensin-converting enzyme (ACE)
in- hibitors
d. Importance of making an annual appointment with the primary care
provider: c.Benefits and side effects of angiotensin-converting enzyme
(ACE) in- hibitors
The core measures for the treatment of heart failure established by The
Joint Commission indicate that patients with an ejection fraction (EF)
<40% receive an ACE inhibitor to decrease the progression of heart
failure.
Aerobic exercise may not be appropriate for a patient with this level of
heart failure, salt substitutes are not usually recommended because of
the risk of hyperkalemia, and the patient will need to see the primary
care provider more frequently than annually.
6.IV sodium nitroprusside (Nipride) is ordered for a patient with acute pul-
monary edema. During the first hours of administration, the nurse will need
to titrate the nitroprusside rate if the patient develops
a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP <90 mm Hg.
, A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
d. a heart rate <50 beats/minute.: c.a systolic BP <90 mm Hg.
Sodium nitroprusside is a potent vasodilator, and the major adverse
effect is severe
1.The home care nurse visits a patient with chronic heart failure who is
taking digoxin and furosemide. The patient complains of nausea and
vomiting. Which action is most appropriate for the nurse to take?
A:Perform a dipstick urine test for protein.
B:Notify the health care provider immediately.
C: Have the patient eat foods high in
potassium.
D:Ask the patient to record a weight every morning.: B: Notify the health
care provider immediately.
2.A patient with left-sided heart failure is prescribed oxygen at 4 L/min per
nasal cannula, furosemide, spironolactone, and enalapril. Which
assessment should the nurse complete to best evaluate the patient's
response to these drugs?
A: Observe skin turgor
B: Auscultate lung sounds
C: Measure blood pressure
D: Review intake and output: B: Auscultate lung sounds
Left = Lungs
3.While assessing a 68-year-old with ascites, the nurse also notes jugular
venous distention (JVD) with the head of the patient's bed elevated 45
degrees.
The nurse knows this finding indicates
a.decreased fluid volume.
b.jugular vein atherosclerosis.
c.increased right atrial pressure.
d.incompetent jugular vein valves.: c.increased right atrial pressure.
The jugular veins empty into the superior vena cava and then into the
right atrium, so JVD with the patient sitting at a 45-degree angle reflects
increased right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not
decreased fluid volume. JVD is not caused by incompetent jugular vein
valves or atherosclerosis.
4.The nurse is caring for a patient who is receiving IV furosemide (Lasix)
and morphine for the treatment of acute decompensated heart failure
(ADHF) with severe orthopnea. Which clinical finding is the best indicator
that the treatment has been effective?
, A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
a. Weight loss of 2 pounds in 24 hours
, A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
b. Hourly urine output greater than 60 mL
c.Reduction in patient complaints of chest
pain
d.Reduced dyspnea with the head of bed at 30 degrees: d.Reduced
dyspnea with the head of bed at 30 degrees
Because the patient's major clinical manifestation of ADHF is orthopnea
(caused by the presence of fluid in the alveoli), the best indicator that
the medications are effective is a decrease in dyspnea with the head of
the bed at 30 degrees. The other assessment data also may indicate
that diuresis or improvement in cardiac output has occurred, but are
not as specific to evaluating this patient's response.
5.Which topic will the nurse plan to include in discharge teaching for a
patient with systolic heart failure and an ejection fraction of 33%?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Benefits and side effects of angiotensin-converting enzyme (ACE)
in- hibitors
d. Importance of making an annual appointment with the primary care
provider: c.Benefits and side effects of angiotensin-converting enzyme
(ACE) in- hibitors
The core measures for the treatment of heart failure established by The
Joint Commission indicate that patients with an ejection fraction (EF)
<40% receive an ACE inhibitor to decrease the progression of heart
failure.
Aerobic exercise may not be appropriate for a patient with this level of
heart failure, salt substitutes are not usually recommended because of
the risk of hyperkalemia, and the patient will need to see the primary
care provider more frequently than annually.
6.IV sodium nitroprusside (Nipride) is ordered for a patient with acute pul-
monary edema. During the first hours of administration, the nurse will need
to titrate the nitroprusside rate if the patient develops
a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP <90 mm Hg.
, A&E II EXAM 2 EXAM QUESTIONS WITH CORRECT ANSWERS
d. a heart rate <50 beats/minute.: c.a systolic BP <90 mm Hg.
Sodium nitroprusside is a potent vasodilator, and the major adverse
effect is severe
