,NU448/NU 448 Adult Health III Exam 2
| Herzing University |Q&A| 26/27
Actual (PDF)
1. A client with acute decompensated heart failure is receiving intravenous furosemide. Which
assessment finding indicates the medication is achieving its therapeutic effect?
A) Decreased urine output and weight gain
B) Decreased jugular venous distension and clear lung sounds
C) Increased heart rate and bounding pulses
D) Increased respiratory rate and crackles
Correct Answer: Decreased jugular venous distension and clear lung sounds
Rationale: Furosemide is a loop diuretic that reduces preload by promoting diuresis and decreasing
intravascular volume. In acute decompensated heart failure, therapeutic effectiveness is
demonstrated by reduced venous congestion (decreased jugular venous distension) and improved
pulmonary congestion (clear lung sounds). Distractor A reflects worsening fluid retention. Distractor C
suggests fluid overload and compensatory tachycardia. Distractor D indicates pulmonary edema
rather than improvement. The nurse should also monitor urine output and daily weights, but jugular
venous distension and lung sounds are direct indicators of reduced preload and pulmonary
congestion.
2. A client recovering from an acute myocardial infarction is being taught about resuming sexual
activity. Which statement by the client indicates a correct understanding of the teaching?
A) "I should wait at least six weeks and then resume activity without restrictions."
,B) "I can resume sexual activity when I can climb two flights of stairs without chest pain or dyspnea."
C) "I should take nitroglycerin immediately before sexual activity to prevent chest pain."
D) "Sexual activity is permanently contraindicated after a myocardial infarction."
Correct Answer: "I can resume sexual activity when I can climb two flights of stairs without chest pain
or dyspnea."
Rationale: The metabolic equivalent (MET) demand of sexual activity is approximately equivalent to
climbing two flights of stairs. The client can safely resume sexual activity when able to perform this
level of exertion without anginal symptoms or dyspnea. Waiting six weeks without assessment is
arbitrary and not evidence-based. Taking nitroglycerin prophylactically before sexual activity is
appropriate for some clients but is not the primary criterion for readiness. Sexual activity is not
permanently contraindicated. Therefore, the ability to climb two flights of stairs without symptoms is
the correct indicator.
3. A client with a new permanent pacemaker is being discharged. Which instruction is essential for the
nurse to include?
A) Avoid all sources of electromagnetic interference
B) Count the pulse daily and report rates below the set rate
C) Sleep only on the left side to stabilize the device
D) Return to the hospital weekly for pacemaker reprogramming
Correct Answer: Count the pulse daily and report rates below the set rate
, Rationale: Clients with a permanent pacemaker should monitor their pulse daily and report rates
below the programmed rate, which may indicate pacemaker malfunction or battery depletion.
Avoiding all electromagnetic interference is unnecessary; most household devices are safe, and
general precautions are sufficient. Sleeping only on the left side is not required. Weekly
reprogramming is not standard; pacemakers are checked periodically (e.g., every 3-6 months).
Therefore, daily pulse monitoring is the essential instruction.
4. A client is admitted with a diagnosis of infective endocarditis. Which assessment finding is most
consistent with this diagnosis?
A) New-onset diastolic murmur
B) Pericardial friction rub
C) Pulsus paradoxus
D) Jugular venous distension
Correct Answer: New-onset diastolic murmur
Rationale: Infective endocarditis commonly causes valvular damage, leading to new or changed
murmurs. A diastolic murmur is particularly concerning because it may indicate aortic regurgitation, a
serious complication. A pericardial friction rub suggests pericarditis. Pulsus paradoxus is associated
with cardiac tamponade. Jugular venous distension suggests right-sided heart failure. Therefore, a
new-onset diastolic murmur is most consistent with infective endocarditis.
5. A client is receiving a continuous intravenous infusion of heparin for treatment of a pulmonary
embolism. Which laboratory value requires immediate intervention?
A) aPTT of 45 seconds
| Herzing University |Q&A| 26/27
Actual (PDF)
1. A client with acute decompensated heart failure is receiving intravenous furosemide. Which
assessment finding indicates the medication is achieving its therapeutic effect?
A) Decreased urine output and weight gain
B) Decreased jugular venous distension and clear lung sounds
C) Increased heart rate and bounding pulses
D) Increased respiratory rate and crackles
Correct Answer: Decreased jugular venous distension and clear lung sounds
Rationale: Furosemide is a loop diuretic that reduces preload by promoting diuresis and decreasing
intravascular volume. In acute decompensated heart failure, therapeutic effectiveness is
demonstrated by reduced venous congestion (decreased jugular venous distension) and improved
pulmonary congestion (clear lung sounds). Distractor A reflects worsening fluid retention. Distractor C
suggests fluid overload and compensatory tachycardia. Distractor D indicates pulmonary edema
rather than improvement. The nurse should also monitor urine output and daily weights, but jugular
venous distension and lung sounds are direct indicators of reduced preload and pulmonary
congestion.
2. A client recovering from an acute myocardial infarction is being taught about resuming sexual
activity. Which statement by the client indicates a correct understanding of the teaching?
A) "I should wait at least six weeks and then resume activity without restrictions."
,B) "I can resume sexual activity when I can climb two flights of stairs without chest pain or dyspnea."
C) "I should take nitroglycerin immediately before sexual activity to prevent chest pain."
D) "Sexual activity is permanently contraindicated after a myocardial infarction."
Correct Answer: "I can resume sexual activity when I can climb two flights of stairs without chest pain
or dyspnea."
Rationale: The metabolic equivalent (MET) demand of sexual activity is approximately equivalent to
climbing two flights of stairs. The client can safely resume sexual activity when able to perform this
level of exertion without anginal symptoms or dyspnea. Waiting six weeks without assessment is
arbitrary and not evidence-based. Taking nitroglycerin prophylactically before sexual activity is
appropriate for some clients but is not the primary criterion for readiness. Sexual activity is not
permanently contraindicated. Therefore, the ability to climb two flights of stairs without symptoms is
the correct indicator.
3. A client with a new permanent pacemaker is being discharged. Which instruction is essential for the
nurse to include?
A) Avoid all sources of electromagnetic interference
B) Count the pulse daily and report rates below the set rate
C) Sleep only on the left side to stabilize the device
D) Return to the hospital weekly for pacemaker reprogramming
Correct Answer: Count the pulse daily and report rates below the set rate
, Rationale: Clients with a permanent pacemaker should monitor their pulse daily and report rates
below the programmed rate, which may indicate pacemaker malfunction or battery depletion.
Avoiding all electromagnetic interference is unnecessary; most household devices are safe, and
general precautions are sufficient. Sleeping only on the left side is not required. Weekly
reprogramming is not standard; pacemakers are checked periodically (e.g., every 3-6 months).
Therefore, daily pulse monitoring is the essential instruction.
4. A client is admitted with a diagnosis of infective endocarditis. Which assessment finding is most
consistent with this diagnosis?
A) New-onset diastolic murmur
B) Pericardial friction rub
C) Pulsus paradoxus
D) Jugular venous distension
Correct Answer: New-onset diastolic murmur
Rationale: Infective endocarditis commonly causes valvular damage, leading to new or changed
murmurs. A diastolic murmur is particularly concerning because it may indicate aortic regurgitation, a
serious complication. A pericardial friction rub suggests pericarditis. Pulsus paradoxus is associated
with cardiac tamponade. Jugular venous distension suggests right-sided heart failure. Therefore, a
new-onset diastolic murmur is most consistent with infective endocarditis.
5. A client is receiving a continuous intravenous infusion of heparin for treatment of a pulmonary
embolism. Which laboratory value requires immediate intervention?
A) aPTT of 45 seconds
