NUR242 MEDICAL SURGICAL NURSING 3
PRACTICE SOLUTION 2026 VIEW AHEAD
TESTED SET
◉ When the clinic nurse is teaching a group of clients with heart
failure (HF) about dietary interventions to prevent fluid overload,
which topic will be included? Answer: Use of fresh or frozen
vegetables instead of canned ones / low sodium
◉ Which action would the nurse take first when a client with heart
failure has an episode of paroxysmal nocturnal dyspnea (PND)?
Answer: Assist the client to sit on the edge of the bed
◉ When caring for a client with a diagnosis of right ventricular heart
failure, the nurse expects which assessment findings? Select all that
apply. One, some, or all responses may be correct. Answer:
Dependent edema
Swollen hands and fingers
Right upper quadrant discomfort
◉ The nurse's physical assessment of a client with heart failure
reveals tachypnea and bilateral crackles. Which is the priority
nursing intervention? Answer: Place client in a high-Fowler position.
,◉ Which treatment would the nurse anticipate when caring for an
infant with heart failure? Answer: Medications that are prescribed
for both children and adults
◉ Which feeding education would the nurse provide the parent of a
2-month-old infant with the diagnosis of heart failure? Answer: Feed
slowly while allowing time for adequate periods of rest
◉ Which assessment finding would indicate improvement in a 4-
month-old infant admitted to the pediatric unit with a diagnosis of
congestive heart failure? Answer: Weight loss during next 2 days
◉ The parent of an infant with heart failure questions the necessity
of weighing the baby every morning. Which would the nurse say that
this daily information is important in determining? Answer: fluid
retention
◉ While auscultating the heart, a health care provider notices S 3
heart sounds in four clients. Which client is at highest risk for heart
failure? Answer: Older adult client
◉ Which assessment finding is a late sign of heart failure? Answer:
Peripheral edema
,◉ Heart failure develops in a 4-month-old infant with a congenital
heart defect, and the infant exhibits marked dyspnea at rest. Which
assessment finding would the nurse expect in this infant? Answer:
Bilateral crackles
◉ Which method would the nurse use to weigh a 2-month-old in
heart failure with practitioner orders for semi-Fowler positioning?
Answer: Placing the infant in an infant seat, recording the weight,
and then subtracting the weight of the seat
◉ Which early sign of heart failure would the nurse recognize in an
infant who has a congenital heart defect with left-to-right shunting
of blood? Answer: Increased respiratory rate
◉ A 2-month-old infant with the diagnosis of heart failure is
discharged with a prescription for oral digoxin 0.05 mg every 12
hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item
would the nurse teach the mother to use when administering the
medication? Answer: Calibrated syringe
◉ An infant with a diagnosis of heart failure is being given
furosemide twice a day. Which laboratory value would the nurse
report to the health care provider? Answer: Potassium of 3.0 mEq/L
(3.0 mmol/L)
, ◉ A client with congestive heart failure is receiving intravenous
digoxin (Cardoxin) therapy. The registered nurse identifies that
which items on the client's care plan are appropriate for a licensed
practical nurse (LPN) to perform? Select all that apply. One, some, or
all responses may be correct. Answer: Help the client ambulate
when required.
Monitor the client's vitals every 30 minutes
Administer adequate oral fluids to the client
◉ The nurse taught a client with heart failure who is scheduled for
discharge about how medications, diet, and exercise improve
activity tolerance. During a follow-up visit, the nurse finds that the
client has learned how to adapt his or her exercise prescription to
increase activity tolerance. Which theory did the nurse follow to
achieve this positive outcome? Answer: Roy's theory
◉ Which intervention would the nurse use after observing that a 6-
month-old child lies quietly, rarely smiles or babbles, and has his
basic needs barely met by the primary caregiver, who is a
grandparent with chronic heart failure? Answer: Initiate a referral
for assessment of home health and schedule a family conference.
◉ A client with heart failure weighed 175 lb (79.4 kg) yesterday, and
today's weight is 181 lb (82.1 kg). How many milliliters of fluid has
the client retained? . ___mL Answer: 2700 ml
PRACTICE SOLUTION 2026 VIEW AHEAD
TESTED SET
◉ When the clinic nurse is teaching a group of clients with heart
failure (HF) about dietary interventions to prevent fluid overload,
which topic will be included? Answer: Use of fresh or frozen
vegetables instead of canned ones / low sodium
◉ Which action would the nurse take first when a client with heart
failure has an episode of paroxysmal nocturnal dyspnea (PND)?
Answer: Assist the client to sit on the edge of the bed
◉ When caring for a client with a diagnosis of right ventricular heart
failure, the nurse expects which assessment findings? Select all that
apply. One, some, or all responses may be correct. Answer:
Dependent edema
Swollen hands and fingers
Right upper quadrant discomfort
◉ The nurse's physical assessment of a client with heart failure
reveals tachypnea and bilateral crackles. Which is the priority
nursing intervention? Answer: Place client in a high-Fowler position.
,◉ Which treatment would the nurse anticipate when caring for an
infant with heart failure? Answer: Medications that are prescribed
for both children and adults
◉ Which feeding education would the nurse provide the parent of a
2-month-old infant with the diagnosis of heart failure? Answer: Feed
slowly while allowing time for adequate periods of rest
◉ Which assessment finding would indicate improvement in a 4-
month-old infant admitted to the pediatric unit with a diagnosis of
congestive heart failure? Answer: Weight loss during next 2 days
◉ The parent of an infant with heart failure questions the necessity
of weighing the baby every morning. Which would the nurse say that
this daily information is important in determining? Answer: fluid
retention
◉ While auscultating the heart, a health care provider notices S 3
heart sounds in four clients. Which client is at highest risk for heart
failure? Answer: Older adult client
◉ Which assessment finding is a late sign of heart failure? Answer:
Peripheral edema
,◉ Heart failure develops in a 4-month-old infant with a congenital
heart defect, and the infant exhibits marked dyspnea at rest. Which
assessment finding would the nurse expect in this infant? Answer:
Bilateral crackles
◉ Which method would the nurse use to weigh a 2-month-old in
heart failure with practitioner orders for semi-Fowler positioning?
Answer: Placing the infant in an infant seat, recording the weight,
and then subtracting the weight of the seat
◉ Which early sign of heart failure would the nurse recognize in an
infant who has a congenital heart defect with left-to-right shunting
of blood? Answer: Increased respiratory rate
◉ A 2-month-old infant with the diagnosis of heart failure is
discharged with a prescription for oral digoxin 0.05 mg every 12
hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item
would the nurse teach the mother to use when administering the
medication? Answer: Calibrated syringe
◉ An infant with a diagnosis of heart failure is being given
furosemide twice a day. Which laboratory value would the nurse
report to the health care provider? Answer: Potassium of 3.0 mEq/L
(3.0 mmol/L)
, ◉ A client with congestive heart failure is receiving intravenous
digoxin (Cardoxin) therapy. The registered nurse identifies that
which items on the client's care plan are appropriate for a licensed
practical nurse (LPN) to perform? Select all that apply. One, some, or
all responses may be correct. Answer: Help the client ambulate
when required.
Monitor the client's vitals every 30 minutes
Administer adequate oral fluids to the client
◉ The nurse taught a client with heart failure who is scheduled for
discharge about how medications, diet, and exercise improve
activity tolerance. During a follow-up visit, the nurse finds that the
client has learned how to adapt his or her exercise prescription to
increase activity tolerance. Which theory did the nurse follow to
achieve this positive outcome? Answer: Roy's theory
◉ Which intervention would the nurse use after observing that a 6-
month-old child lies quietly, rarely smiles or babbles, and has his
basic needs barely met by the primary caregiver, who is a
grandparent with chronic heart failure? Answer: Initiate a referral
for assessment of home health and schedule a family conference.
◉ A client with heart failure weighed 175 lb (79.4 kg) yesterday, and
today's weight is 181 lb (82.1 kg). How many milliliters of fluid has
the client retained? . ___mL Answer: 2700 ml
