, NSG 430 Exam 2 – Adult Health Nursing II
Actual Questions & Answers (GCU) 100%
Guarantee Pass
Q1. The nurse obtains a health history from a 65-year-old patient with a prosthetic
mitral valve who has symptoms of infective endocarditis (IE). Which question by
the nurse is most appropriate?
A. "Do you ever wake up at night short of breath?"
B. "Have you had dental work done recently?"
C. "How often do you check your blood pressure at home?"
D. "Have you recently traveled outside the country?"
Answer: B. "Have you had dental work done recently?"
Rationale: Dental procedures can cause transient bacteremia, a major risk factor for
infective endocarditis in patients with prosthetic valves. Identifying this potential source
helps guide diagnosis and prevention.
Q2. The nurse identifies the nursing diagnosis of decreased cardiac output related
to valvular insufficiency for the patient with infective endocarditis (IE) based on
which assessment finding?
A. Weight gain of 2 lb in 2 days
B. Urine output less than 30 mL/hr
C. Heart rate 102 beats/min
D. Crackles at the lung bases
Answer: B. Urine output less than 30 mL/hr
Rationale: Low urine output indicates decreased renal perfusion, a sensitive indicator of
reduced cardiac output. Valvular insufficiency in IE can impair forward flow, leading to
poor organ perfusion and oliguria.
,Q3. During the assessment of a 25-year-old patient with infective endocarditis (IE),
what would the nurse expect to find?
A. Bounding peripheral pulses
B. A new regurgitant murmur
C. Bradycardia with extra heart sounds
D. Clear heart sounds without murmurs
Answer: B. A new regurgitant murmur
Rationale: IE frequently damages valve leaflets, leading to new or changing murmurs,
especially regurgitant murmurs, which are classic physical findings.
Q4. Which assessment finding obtained by the nurse when assessing a patient with
acute pericarditis should be reported immediately to the health care provider?
A. Pericardial friction rub
B. Pleuritic chest pain
C. Jugular venous distention (JVD) to jaw level and edema
D. Low-grade fever
Answer: C. Jugular venous distention (JVD) to jaw level and edema
Rationale: JVD and edema suggest impaired venous return, raising concern for cardiac
tamponade—a life-threatening complication requiring urgent intervention.
Q5. A patient is recovering from a myocardial infarction (MI) and develops chest
pain on day 3 that increases when taking a deep breath and is relieved by leaning
forward. Which action should the nurse take next?
A. Call the provider for a stat troponin level
B. Give sublingual nitroglycerin
C. Auscultate for a pericardial friction rub
D. Place patient flat in bed
Answer: C. Auscultate for a pericardial friction rub
, Rationale: Pleuritic chest pain relieved by leaning forward post-MI suggests pericarditis
(Dressler's syndrome). Listening for a pericardial friction rub helps confirm this diagnosis.
Q6. When caring for a patient with mitral valve stenosis, it is most important that
the nurse assess for:
A. Peripheral edema
B. Shortness of breath on exertion
C. Claudication pain
D. Syncope with position changes
Answer: B. Shortness of breath on exertion
Rationale: Mitral stenosis impairs left atrial emptying, increasing pulmonary pressures
and leading to exertional dyspnea—one of the most common and important symptoms.
Q7. After receiving report on the following patients, which patient should the
nurse assess first?
A. Patient post-CABG with incisional pain
B. Patient with chronic atrial fibrillation and HR 92
C. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
D. Patient scheduled for a stress test tomorrow
Answer: C. Patient with acute aortic regurgitation whose blood pressure is 86/54
mm Hg
Rationale: Hypotension in acute aortic regurgitation may indicate cardiogenic shock
and compromised perfusion; this is an immediate priority.
Q8. A 72-year-old man with a history of aortic stenosis is admitted to the
emergency department. He reports severe left-sided chest pressure radiating to
the jaw. Which medication, if ordered by the health care provider, should the nurse
question?
Actual Questions & Answers (GCU) 100%
Guarantee Pass
Q1. The nurse obtains a health history from a 65-year-old patient with a prosthetic
mitral valve who has symptoms of infective endocarditis (IE). Which question by
the nurse is most appropriate?
A. "Do you ever wake up at night short of breath?"
B. "Have you had dental work done recently?"
C. "How often do you check your blood pressure at home?"
D. "Have you recently traveled outside the country?"
Answer: B. "Have you had dental work done recently?"
Rationale: Dental procedures can cause transient bacteremia, a major risk factor for
infective endocarditis in patients with prosthetic valves. Identifying this potential source
helps guide diagnosis and prevention.
Q2. The nurse identifies the nursing diagnosis of decreased cardiac output related
to valvular insufficiency for the patient with infective endocarditis (IE) based on
which assessment finding?
A. Weight gain of 2 lb in 2 days
B. Urine output less than 30 mL/hr
C. Heart rate 102 beats/min
D. Crackles at the lung bases
Answer: B. Urine output less than 30 mL/hr
Rationale: Low urine output indicates decreased renal perfusion, a sensitive indicator of
reduced cardiac output. Valvular insufficiency in IE can impair forward flow, leading to
poor organ perfusion and oliguria.
,Q3. During the assessment of a 25-year-old patient with infective endocarditis (IE),
what would the nurse expect to find?
A. Bounding peripheral pulses
B. A new regurgitant murmur
C. Bradycardia with extra heart sounds
D. Clear heart sounds without murmurs
Answer: B. A new regurgitant murmur
Rationale: IE frequently damages valve leaflets, leading to new or changing murmurs,
especially regurgitant murmurs, which are classic physical findings.
Q4. Which assessment finding obtained by the nurse when assessing a patient with
acute pericarditis should be reported immediately to the health care provider?
A. Pericardial friction rub
B. Pleuritic chest pain
C. Jugular venous distention (JVD) to jaw level and edema
D. Low-grade fever
Answer: C. Jugular venous distention (JVD) to jaw level and edema
Rationale: JVD and edema suggest impaired venous return, raising concern for cardiac
tamponade—a life-threatening complication requiring urgent intervention.
Q5. A patient is recovering from a myocardial infarction (MI) and develops chest
pain on day 3 that increases when taking a deep breath and is relieved by leaning
forward. Which action should the nurse take next?
A. Call the provider for a stat troponin level
B. Give sublingual nitroglycerin
C. Auscultate for a pericardial friction rub
D. Place patient flat in bed
Answer: C. Auscultate for a pericardial friction rub
, Rationale: Pleuritic chest pain relieved by leaning forward post-MI suggests pericarditis
(Dressler's syndrome). Listening for a pericardial friction rub helps confirm this diagnosis.
Q6. When caring for a patient with mitral valve stenosis, it is most important that
the nurse assess for:
A. Peripheral edema
B. Shortness of breath on exertion
C. Claudication pain
D. Syncope with position changes
Answer: B. Shortness of breath on exertion
Rationale: Mitral stenosis impairs left atrial emptying, increasing pulmonary pressures
and leading to exertional dyspnea—one of the most common and important symptoms.
Q7. After receiving report on the following patients, which patient should the
nurse assess first?
A. Patient post-CABG with incisional pain
B. Patient with chronic atrial fibrillation and HR 92
C. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
D. Patient scheduled for a stress test tomorrow
Answer: C. Patient with acute aortic regurgitation whose blood pressure is 86/54
mm Hg
Rationale: Hypotension in acute aortic regurgitation may indicate cardiogenic shock
and compromised perfusion; this is an immediate priority.
Q8. A 72-year-old man with a history of aortic stenosis is admitted to the
emergency department. He reports severe left-sided chest pressure radiating to
the jaw. Which medication, if ordered by the health care provider, should the nurse
question?
