NUR 320: Exam #3 Review Questions And
Correct Answers (Already Graded A+) | New
Update 2025
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The
nurse expects what assessment findings associated with right-sided heart failure?
Select all that apply.
Dependent edema
Swollen hands and fingers
Collapsed neck veins
Right upper quadrant discomfort
Oliguria - ANSWER Dependent edema
Swollen hands and fingers
R upper quadrant discomfort
Rationale: With right-sided heart failure, signs of systemic congestion occur as the
right ventricle fails; key features include dependent edema and swollen hands and
fingers. Upper right quadrant discomfort is expected with right ventricular failure
because venous congestion in the systemic circulation results in hepatomegaly.
Jugular venous collapse and oliguria are key features of left-sided heart failure.
Left-sided heart failure is associated with decreased cardiac output.
,An infant who has a congenital heart defect with left-to-right shunting of blood is
admitted to the pediatric unit. What early sign of heart failure should the nurse
identify?
Cyanosis
Restlessness
Decreased heart rate
Increased respiratory rate - ANSWER Increased respiratory rate
Rationale: Because the lungs are stressed by pulmonary edema, a quicker
respiratory rate is the first and most reliable indicator of early heart failure in
infants. Cyanosis is a late sign of heart failure; with early failure there is still
adequate perfusion of blood. Infants with early heart failure do not move about;
they become fatigued quickly, especially when feeding, because of a decrease of
oxygen to body cells. The heart rate of an infant in early heart failure increases,
not decreases, in an attempt to increase oxygen to body cells.
The nurse instructs the client admitted for an acute exacerbation of chronic
obstructive pulmonary disease (COPD) about the importance of assessing for
right-sided heart failure after discharge. What does the nurse instruct the client to
assess for?
Increased appetite
,Clubbing of the nail beds
Hypertension
Weight gain - ANSWER Weight gain
Rationale: The most common signs and symptoms of right-sided heart failure are
hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients
with right-sided heart failure often have decreased appetites. Clubbing is
indicative of hypoxemia. Hypertension is associated with left-sided heart failure.
The nurse is caring for a client who is admitted to the hospital with early heart
failure. Which client statement indicates a clinical manifestation that is related to
heart failure?
I see spots before my eyes.
I am tired at the end of the day.
I feel bloated when I eat a large meal.
I have trouble breathing when I climb a flight of stairs. - ANSWER I have
trouble breathing when I climb a flight of stairs.
, Rationale: Dyspnea on exertion occurs with heart failure because of the heart's
inability to meet the oxygen needs of the body. Seeing spots before one's eyes,
being tired at the end of the day, and feeling bloated are not specific to heart
failure.
A client is diagnosed with heart failure and is admitted for medical management.
Which statement made by the client may indicate worsening heart failure?
"I am unable to run a mile (1.6 kilometers) now."
"I wake up at night short of breath."
"My wife says I snore very loudly."
"My shoes seem larger lately." - ANSWER "I wake up at night short of breath."
Rationale: Increased shortness of breath is often an indicator of fluid overload in
the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly,
and shoes seeming larger are not as related to heart failure as waking up at night
with shortness of breath.
A nurse is caring for an infant with heart failure. What treatment does the nurse
most likely anticipate in the care of this infant?
Open heart surgery
Correct Answers (Already Graded A+) | New
Update 2025
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The
nurse expects what assessment findings associated with right-sided heart failure?
Select all that apply.
Dependent edema
Swollen hands and fingers
Collapsed neck veins
Right upper quadrant discomfort
Oliguria - ANSWER Dependent edema
Swollen hands and fingers
R upper quadrant discomfort
Rationale: With right-sided heart failure, signs of systemic congestion occur as the
right ventricle fails; key features include dependent edema and swollen hands and
fingers. Upper right quadrant discomfort is expected with right ventricular failure
because venous congestion in the systemic circulation results in hepatomegaly.
Jugular venous collapse and oliguria are key features of left-sided heart failure.
Left-sided heart failure is associated with decreased cardiac output.
,An infant who has a congenital heart defect with left-to-right shunting of blood is
admitted to the pediatric unit. What early sign of heart failure should the nurse
identify?
Cyanosis
Restlessness
Decreased heart rate
Increased respiratory rate - ANSWER Increased respiratory rate
Rationale: Because the lungs are stressed by pulmonary edema, a quicker
respiratory rate is the first and most reliable indicator of early heart failure in
infants. Cyanosis is a late sign of heart failure; with early failure there is still
adequate perfusion of blood. Infants with early heart failure do not move about;
they become fatigued quickly, especially when feeding, because of a decrease of
oxygen to body cells. The heart rate of an infant in early heart failure increases,
not decreases, in an attempt to increase oxygen to body cells.
The nurse instructs the client admitted for an acute exacerbation of chronic
obstructive pulmonary disease (COPD) about the importance of assessing for
right-sided heart failure after discharge. What does the nurse instruct the client to
assess for?
Increased appetite
,Clubbing of the nail beds
Hypertension
Weight gain - ANSWER Weight gain
Rationale: The most common signs and symptoms of right-sided heart failure are
hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients
with right-sided heart failure often have decreased appetites. Clubbing is
indicative of hypoxemia. Hypertension is associated with left-sided heart failure.
The nurse is caring for a client who is admitted to the hospital with early heart
failure. Which client statement indicates a clinical manifestation that is related to
heart failure?
I see spots before my eyes.
I am tired at the end of the day.
I feel bloated when I eat a large meal.
I have trouble breathing when I climb a flight of stairs. - ANSWER I have
trouble breathing when I climb a flight of stairs.
, Rationale: Dyspnea on exertion occurs with heart failure because of the heart's
inability to meet the oxygen needs of the body. Seeing spots before one's eyes,
being tired at the end of the day, and feeling bloated are not specific to heart
failure.
A client is diagnosed with heart failure and is admitted for medical management.
Which statement made by the client may indicate worsening heart failure?
"I am unable to run a mile (1.6 kilometers) now."
"I wake up at night short of breath."
"My wife says I snore very loudly."
"My shoes seem larger lately." - ANSWER "I wake up at night short of breath."
Rationale: Increased shortness of breath is often an indicator of fluid overload in
the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly,
and shoes seeming larger are not as related to heart failure as waking up at night
with shortness of breath.
A nurse is caring for an infant with heart failure. What treatment does the nurse
most likely anticipate in the care of this infant?
Open heart surgery
