Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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 90 and CRT less than three (3) seconds.
1
1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds,
lung congestion, and change in mental status.
2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing.
3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored
breathing, not eupnea, which means normal breathing.
4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.
TEST-TAKING HINT: In option "3," the word "no" is an absolute term and, usually, absolutes, such as "no," "never,"
"always," and "only," are incorrect because there is no room for any other possible answer. If the test taker is looking for
abnormal data, then the test taker should exclude the options that have normal values in them, such as eupnea, pulse rate of
90, and capillary refill time (CRT) less than three (3) seconds.
1 Congestive Heart Failure Test 5 Practice Questions.pdf
,Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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. The client will be able to ambulate in the hall by date of discharge.
2. The client will have an audible S1 and S2 with no S3 heard by end of shift.
3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day
two (2) of care
2
1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis.
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.
3. This is a nursing intervention, not a short-term goal, for this client.
4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output.
TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected
addresses the problem. An answer option may be appropriate care for the disease process but may not fit with the problem or
etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem
(etiology). In this question the test taker should look for an answer that addresses the ability of the heart to pump blood.
2 Congestive Heart Failure Test 5 Practice Questions.pdf
,Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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 the health-care provider of a weight gain of more than one (1) pound in a week.
2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
3. Instruct the client to remove the saltshaker from the dinner table.
4. Encourage the client to monitor urine output for change in color to become dark.
5. Discuss the importance of taking the loop diuretic furosemide at bedtime.
2,3
1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day.
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 prevent water retention.
4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase
with diuretics.
5. Instruct the client to take the diuretic in the morning to prevent nocturia.
TEST-TAKING HINT: This is an alternative-type question—in this case, "Select all that apply." If the test taker missed this
statement, it is possible to jump at the first correct answer. This is one reason that it is imperative to read all options before
deciding on the correct one(s). This could be a clue to reread the question for clarity. Another hint that this is an alternative
question is the number of options. The other questions have four potential answers; this one has five. Numbers in an answer
option are always important. Is one (1) pound enough to indicate a problem that should be brought to the attention of the
health-care provider?
3 Congestive Heart Failure Test 5 Practice Questions.pdf
, Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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 to a sitting position
4
1. Sponging dry the client's forehead would be appropriate, but it is not the first intervention.
2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention.
3. Taking the vital signs would be appropriate, but it is not the first intervention.
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 could take vital signs and check the pulse oximeter and then sponge the
client's forehead.
TEST-TAKING HINT: In a question that asks the nurse to set priorities, all the answer options can be appropriate actions by
the nurse for a given situation. The test taker should apply some guidelines or principles, such as Maslow's hierarchy, to
determine what will give the client the most immediate assistance.
4 Congestive Heart Failure Test 5 Practice Questions.pdf
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 90 and CRT less than three (3) seconds.
1
1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds,
lung congestion, and change in mental status.
2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing.
3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored
breathing, not eupnea, which means normal breathing.
4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.
TEST-TAKING HINT: In option "3," the word "no" is an absolute term and, usually, absolutes, such as "no," "never,"
"always," and "only," are incorrect because there is no room for any other possible answer. If the test taker is looking for
abnormal data, then the test taker should exclude the options that have normal values in them, such as eupnea, pulse rate of
90, and capillary refill time (CRT) less than three (3) seconds.
1 Congestive Heart Failure Test 5 Practice Questions.pdf
,Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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. The client will be able to ambulate in the hall by date of discharge.
2. The client will have an audible S1 and S2 with no S3 heard by end of shift.
3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day
two (2) of care
2
1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis.
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.
3. This is a nursing intervention, not a short-term goal, for this client.
4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output.
TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected
addresses the problem. An answer option may be appropriate care for the disease process but may not fit with the problem or
etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem
(etiology). In this question the test taker should look for an answer that addresses the ability of the heart to pump blood.
2 Congestive Heart Failure Test 5 Practice Questions.pdf
,Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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 the health-care provider of a weight gain of more than one (1) pound in a week.
2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
3. Instruct the client to remove the saltshaker from the dinner table.
4. Encourage the client to monitor urine output for change in color to become dark.
5. Discuss the importance of taking the loop diuretic furosemide at bedtime.
2,3
1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day.
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 prevent water retention.
4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase
with diuretics.
5. Instruct the client to take the diuretic in the morning to prevent nocturia.
TEST-TAKING HINT: This is an alternative-type question—in this case, "Select all that apply." If the test taker missed this
statement, it is possible to jump at the first correct answer. This is one reason that it is imperative to read all options before
deciding on the correct one(s). This could be a clue to reread the question for clarity. Another hint that this is an alternative
question is the number of options. The other questions have four potential answers; this one has five. Numbers in an answer
option are always important. Is one (1) pound enough to indicate a problem that should be brought to the attention of the
health-care provider?
3 Congestive Heart Failure Test 5 Practice Questions.pdf
, Congestive Heart Failure Test 5 Practice Questions Congestive Heart Failure Test 5 Practice Questions
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 to a sitting position
4
1. Sponging dry the client's forehead would be appropriate, but it is not the first intervention.
2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention.
3. Taking the vital signs would be appropriate, but it is not the first intervention.
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 could take vital signs and check the pulse oximeter and then sponge the
client's forehead.
TEST-TAKING HINT: In a question that asks the nurse to set priorities, all the answer options can be appropriate actions by
the nurse for a given situation. The test taker should apply some guidelines or principles, such as Maslow's hierarchy, to
determine what will give the client the most immediate assistance.
4 Congestive Heart Failure Test 5 Practice Questions.pdf
