RNSG 1517 Exam 3 Questions and Correct
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is caring for a client with chronic heart failure who reports
a 3-lb (1.4-kg) weight gain over the past 2 days. Which action
should the nurse take first?
A. Encourage the client to increase oral fluids
B. Administer an additional dose of the prescribed diuretic
C. Notify the healthcare provider of the weight gain
D. Reassure the client that minor weight fluctuations are expected
Answer: C. Notify the healthcare provider of the weight gain
Rationale: A rapid weight gain is a significant indicator of fluid
retention in a client with heart failure and may indicate worsening
cardiac function. The healthcare provider should be notified so the
treatment plan can be evaluated. Nurses should not independently
change medication dosages unless specifically authorized.
, 2. Which assessment finding is most characteristic of left-sided heart
failure?
A. Dependent peripheral edema
B. Jugular venous distention
C. Pulmonary crackles and dyspnea
D. Enlarged liver
Answer: C. Pulmonary crackles and dyspnea
Rationale: Left-sided heart failure causes inadequate forward
pumping of blood from the left ventricle, resulting in pulmonary
vascular congestion. Crackles, dyspnea, orthopnea, and pulmonary
edema may occur. Right-sided heart failure is more commonly
associated with systemic venous congestion, including peripheral
edema, jugular venous distention, and hepatomegaly.
3. A client receiving furosemide reports muscle weakness and
fatigue. Which laboratory value should the nurse assess first?
A. Sodium
B. Potassium
C. Calcium
D. Hemoglobin
,Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of potassium. Hypokalemia can cause muscle weakness,
fatigue, cardiac dysrhythmias, and other complications. Monitoring
serum potassium is therefore important in clients receiving loop
diuretics.
4. A client with angina reports chest discomfort that occurs while
walking and is relieved by rest. How should the nurse interpret
this finding?
A. It is consistent with stable angina
B. It indicates acute myocardial infarction
C. It is characteristic of pericarditis
D. It indicates pulmonary embolism
Answer: A. It is consistent with stable angina
Rationale: Stable angina typically occurs predictably with exertion or
emotional stress because myocardial oxygen demand increases. The
discomfort generally improves with rest or prescribed nitroglycerin.
Unstable angina is more unpredictable and may occur at rest.
, 5. Which statement by a client prescribed sublingual nitroglycerin
indicates correct understanding?
A. “I should swallow the tablet with water.”
B. “I should take the medication only after the pain has lasted 30
minutes.”
C. “I should sit down before taking the medication.”
D. “I should store the tablets in my weekly pill organizer.”
Answer: C. “I should sit down before taking the medication.”
Rationale: Nitroglycerin can cause hypotension and dizziness, so
sitting or lying down before administration reduces the risk of injury
from falling. Sublingual nitroglycerin is placed under the tongue
rather than swallowed. It should be stored according to the
manufacturer's instructions, typically in its original container.
6. A nurse is assessing a client who may be experiencing an acute
myocardial infarction. Which finding requires the most immediate
attention?
A. Mild nausea
B. Chest pressure with diaphoresis
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is caring for a client with chronic heart failure who reports
a 3-lb (1.4-kg) weight gain over the past 2 days. Which action
should the nurse take first?
A. Encourage the client to increase oral fluids
B. Administer an additional dose of the prescribed diuretic
C. Notify the healthcare provider of the weight gain
D. Reassure the client that minor weight fluctuations are expected
Answer: C. Notify the healthcare provider of the weight gain
Rationale: A rapid weight gain is a significant indicator of fluid
retention in a client with heart failure and may indicate worsening
cardiac function. The healthcare provider should be notified so the
treatment plan can be evaluated. Nurses should not independently
change medication dosages unless specifically authorized.
, 2. Which assessment finding is most characteristic of left-sided heart
failure?
A. Dependent peripheral edema
B. Jugular venous distention
C. Pulmonary crackles and dyspnea
D. Enlarged liver
Answer: C. Pulmonary crackles and dyspnea
Rationale: Left-sided heart failure causes inadequate forward
pumping of blood from the left ventricle, resulting in pulmonary
vascular congestion. Crackles, dyspnea, orthopnea, and pulmonary
edema may occur. Right-sided heart failure is more commonly
associated with systemic venous congestion, including peripheral
edema, jugular venous distention, and hepatomegaly.
3. A client receiving furosemide reports muscle weakness and
fatigue. Which laboratory value should the nurse assess first?
A. Sodium
B. Potassium
C. Calcium
D. Hemoglobin
,Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of potassium. Hypokalemia can cause muscle weakness,
fatigue, cardiac dysrhythmias, and other complications. Monitoring
serum potassium is therefore important in clients receiving loop
diuretics.
4. A client with angina reports chest discomfort that occurs while
walking and is relieved by rest. How should the nurse interpret
this finding?
A. It is consistent with stable angina
B. It indicates acute myocardial infarction
C. It is characteristic of pericarditis
D. It indicates pulmonary embolism
Answer: A. It is consistent with stable angina
Rationale: Stable angina typically occurs predictably with exertion or
emotional stress because myocardial oxygen demand increases. The
discomfort generally improves with rest or prescribed nitroglycerin.
Unstable angina is more unpredictable and may occur at rest.
, 5. Which statement by a client prescribed sublingual nitroglycerin
indicates correct understanding?
A. “I should swallow the tablet with water.”
B. “I should take the medication only after the pain has lasted 30
minutes.”
C. “I should sit down before taking the medication.”
D. “I should store the tablets in my weekly pill organizer.”
Answer: C. “I should sit down before taking the medication.”
Rationale: Nitroglycerin can cause hypotension and dizziness, so
sitting or lying down before administration reduces the risk of injury
from falling. Sublingual nitroglycerin is placed under the tongue
rather than swallowed. It should be stored according to the
manufacturer's instructions, typically in its original container.
6. A nurse is assessing a client who may be experiencing an acute
myocardial infarction. Which finding requires the most immediate
attention?
A. Mild nausea
B. Chest pressure with diaphoresis
