Exam 3 v1: NUR242/ NUR 242 | Question and Answers| Latest 2025/ 2026 Update | Medical – Surgical Nursing Concepts | 100% Verified Solutions | GRADED A - Galen

Exam 3 v1: NUR242/ NUR 242 | Question and Answers| Latest 2025/ 2026 Update | Medical – Surgical Nursing Concepts | 100% Verified Solutions | GRADED A - Galen Question: An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate? Answer: TB adversely affects older adults with chronic illness Question: 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 Question: 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 Question: 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 Question: 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. Question: Which treatment would the nurse anticipate when caring for an infant with heart failure? Answer: Medications that are prescribed for both children and adults Question: 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 Question: 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 Question: 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 Question: 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 Question: Which assessment finding is a late sign of heart failure? Answer: Peripheral edema Question: 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 Question: 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 Question: 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 Question: 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 Question: 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) Question: 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 Question: 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 Question: 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. Question: 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 Question: An infant with a congenital heart defect is in heart failure and is receiving daily weight measurements. Which complication of heart failure would daily weights help monitor? Answer: Fluid retention Question: Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot and heart failure? Answer: Providing small, frequent feedings Question: The nurse provides teaching to a client who is being discharged after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor for which indication of right-sided heart failure? Answer: Weight gain Question: When a client with heart failure reports frequent sudden waking during the night with shortness of breath, how will the nurse document this finding? Answer: Paroxysmal nocturnal dyspnea Question: The nurse explains to a pregnant client with a class II heart failure that in pregnancy the cardiac system is most compromised during which time? Answer: First 2 days after the birth Question: Which sign would indicate possible heart failure in a client with heart disease in the immediate postpartum period? Answer: Tachypnea Question: A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day? Answer: Maintaining potassium levels Question: A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day? Answer: Maintaining potassium levels Question: When a client with type 1 diabetes develops heart failure, digoxin is prescribed. Which nursing action is important to include when planning care? Answer: Monitor the client for cardiac dysrhythmias. Question: A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin 0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically effective? Select all that apply. One, some, or all responses may be correct. Answer: Diuresis Decreased edema Decreased pulse rate Question: A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin? Answer: Bradycardia Question: A health care provider prescribes milrinone for a client with congestive heart failure. Which action would the nurse perform first? Answer: Have the prescription, dosage calculations, and pump settings checked by a second nurse Question: Which care plan would the nurse implement for an infant admitted to the pediatric unit with the diagnosis of heart failure? Answer: Offer the infant small, frequent feedings Question: Which parent education would the nurse provide as rationale for gavage feedings in an infant with congestive heart failure? Answer: The energy that would have been expended on suckling is conserved Question: Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider? Answer: Premature ventricular contractions Question: Which statement made by the nursing student requires correction regarding the effect of applying the Roy adaptation model on improved functional status in clients with heart failure? Answer: Use of literature resources supports practical-based nursing interventions." Question: The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? Answer: Shift of fluid into the interstitial spaces Question: A client with heart failure is to receive digoxin. Which therapeutic effect is associated with this medication? Answer: Slows and strengthens cardiac contractions Question: A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. Which nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition? Answer: Auscultating breath sounds Question: Digoxin is prescribed for a client with heart failure. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply. One, some, or all responses may be correct. Answer: Nausea Yellow vision Irregular pulse Question: Which action would the nurse take first when a client who has heart failure reports fatigue and has an increase in heart rate from 90 beats/minute to 120 beats/minute while ambulating? Answer: Have the client sit down and rest Question: When the home care nurse calls to make an appointment for the initial visit with a client who has heart failure, the client reports that many family members are visiting today and requests that the nurse wait a week for the appointment. Which response by the nurse is best? Answer: Tell the client that it might be helpful to talk with family members during the initial visit. Question: Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse? Answer: Oxygen saturation 86% Question: When a client is diagnosed with left-sided congestive heart failure, which assessment findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. Answer: Dyspnea Crackles Frequent cough Question: When assessing a client with chronic heart failure, which clinical finding would the nurse expect to find? Answer: Dependent edema in the evening Question: When a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32 breaths/minute, which action would the nurse take first? Answer: Elevate the head of the bed to 75 degrees. Question: When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? Answer: Using several pillows at night to sleep Question: When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply. One, some, or all responses may be correct. Answer: Intake of salty foods Medication compliance Recent travel Question: How would anxiety affect outcomes for a client with heart failure? Answer: Increases the cardiac workload Question: When a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks, which assessment is the priority? Answer: Auscultate breath sounds. Question: Which statement by a client who is seen for follow-up in the heart failure clinic is most important for the nurse to communicate to the health care provider? Answer: "I wake up at night short of breath" Question: A client with heart failure reports waking suddenly and feeling short of breath during the night. How will the nurse document this information? Answer: Paroxysmal nocturnal dyspnea Question: When a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day, which action would the nurse take next? Perform a head-to-toe assessment. Answer: Question: When caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 beats/minute, and bilateral lung crackles, which prescribed action would the nurse question? Answer: Infuse normal saline at 100 mL/h Question: When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb (2.7 kg), which nursing action has the highest priority? Answer: Listen to the client's breath sounds Question: When caring for a client with heart failure, which type of lung sounds would the nurse expect to hear? Answer: Crackles Question: When reviewing laboratory results for a client with heart failure who has been receiving furosemide daily, the nurse notes a blood urea nitrogen (BUN) of 42 mg/dL (15.2 mmol/L) and a creatinine of 1.1 mg/dL (97 mcmol/L). Which action by the nurse is a priority? Answer: Notifying the health care provider about the results Question: Which topics would be included when teaching a client with heart failure who will be discharged with a new prescription for digoxin? Select all that apply. One, some, or all responses may be correct. Answer: Take your radial pulse daily and write it down. Notify the health care provider if you develop any vision changes Call the health care provider if your pulse is irregular or less than 60 beats/minute Question: When an older client with heart failure is transferred from the emergency department to the medical service, which would the nurse on the unit do first? Answer: Assess the client's heart and lung sounds Question: When teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? Select all that apply. One, some, or all responses may be correct. Extreme fatigue Answer: Coughing at night Difficulty breathing Question: Which medication prescribed for a client with an acute episode of heart failure would the nurse question? Answer: Beta blocker Question: When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? Answer: Weighing the client Question: Which statement by a client is consistent with a diagnosis of heart failure? Answer: "I have trouble breathing when I climb a flight of stairs. Question: Which finding would the nurse expect when caring for a client with right-sided heart failure? Answer: Distended neck veins Question: When the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure, the client becomes irritable and asks why bed rest is needed. Which response by the nurse is best? Answer: Rest reduces the amount of work your heart has to do right now." Question: For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. Answer: Unusual fatigue Dependent edema Nocturnal dyspnea Question: When a client with heart failure is to be discharged and tells the nurse that there are no family members who can help with care at home, which action would the nurse take first? Answer: Question the client about current support systems Question: Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? Answer: Potassium level of 2.3 mEq/L (2.3 mmol/L) Question: Which suggestion would the nurse make for a client with heart failure? Answer: Avoid emotionally stressful situations Question: Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? Answer: Place the client in the orthopneic position Question: The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess? Answer: Tissue ischemia Question: The heartbeat assessment of four clients is given below. Answer: Which client is at an increased risk for right-sided heart failure? Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. This client is at risk for right-sided heart failure. One-sided pressure elevation is caused by obstruction, as observed in clients B, C, and D. Question: A neonate with heart failure is prescribed furosemide. Which changes to the dosage or time intervals between doses would the nurse make? Answer: The time between doses should be lengthened Question: Which nursing interventions promote safe administration of digoxin in a child diagnosed with heart failure? Select all that apply. One, some, or all responses may be correct. Answer: Checking for compliance with the client's medication regimen Monitoring the client's serum potassium and magnesium levels regularly Calculating the correct dosage form, prescribed amounts, and the prescriber's prescription Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly Question: Which education would the nurse teach the parents of an infant with a cardiac defect about an early sign of heart failure? Answer: Increased heart rate Question: When assessing a client with heart failure for activity tolerance, which activity would the nurse expect to cause the most distress for the client? Answer: Climbing a flight of stairs to the bedroom Question: Which diet choices by a client who has heart failure indicate that the nurse's teaching about diet has been effective? Select all that apply. One, some, or all responses may be correct. Answer: Low sodium- Lean steak Fruit salad Broiled chicken Roasted potatoes Question: When caring for an older client who has had multiple recent hospital admissions for heart failure, which action would the nurse take first? Answer: Ask the client about medication use and activity level at home Question: Which assessment findings are consistent with a client diagnosis of right-sided heart failure? Select all that apply. One, some, or all responses may be correct. Answer: Distended abdomen Dependent edema Decreased appetite Question: Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? Answer: Fluid retention Question: How can the nurse describe heart failure to a client? Answer: an inability of the heart to pump blood in proportion to metabolic needs Question: Which action would the nurse manager employ during implementation and evaluation of a quality improvement project to decrease hospital readmissions for heart failure clients? Select all that apply. One, some, or all responses may be correct. Answer: Meeting regularly with staff throughout project implementation Using readmission data for heart failure clients to evaluate project effectiveness Collaborating with staff to address continuing high readmission rates post-project implementation Ensuring that staff are provided time to participate in development and implementation of the new project Coaching staff on effective implementation of the transition of care for heart failure clients being discharged Question: Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. Answer: Diuretics Low-salt diet Daily weight checks Fluid restriction Intake and output Oxygen administration Question: Which parameter would the nurse assess in a client with right-sided heart failure? Select all that apply. One, some, or all responses may be correct. Answer: Fluid volume Question: The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct. Answer: Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds Question: Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. Answer: Fatigue Orthopnea Pitting edema Dry hacking cough 4-pound weight gain Question: The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2-g sodium diet. Which statement from the client indicates that further teaching is needed? Answer: I can use a little table salt on my food as long as I do not use it when cooking food Question: An infant with congenital heart disease is prescribed digoxin and furosemide upon discharge. Which sign would the nurse instruct the parents to be alert for? Answer: Difficulty feeding with vomiting Question: A client, who is currently taking digoxin 0.125 mg in the morning and alprazolam 0.5 mg twice a day, is prescribed donepezil 5 mg daily for early dementia of the Alzheimer type. Which instruction would the nurse include when teaching the client's spouse about medication administration? Answer: Prefill a weekly medication box with the medications for the client to self-administer." Question: The nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin. Which sign of digoxin toxicity would the nurse monitor for? Answer: Vomiting Question: The clinic nurse receives a call from the mother of an infant prescribed digoxin. The mother reports she forgot whether she gave the morning dose of digoxin. Which response by the nurse is most appropriate? Answer: Skip this dose and give it at the next prescribed time. Question: The nurse teaches the parents of a 4-year-old child about the administration of digoxin elixir twice a day. Which statement indicates to the nurse the parents need further teaching? Answer: "We should give the digoxin twice a day, at breakfast and dinner Question: Which lifestyle advice does the nurse give to a client when oral digoxin therapy is initiated? Select all that apply. One, some, or all responses may be correct. Answer: Bran can decrease digoxin absorption. Digoxin should not be taken with hawthorn supplements. Ginseng may cause a dangerous increase in digoxin levels in the blood. Medications that lower serum potassium or magnesium can cause digoxin toxicity. Question: According to developmental norms for a 5-year-old child, the nurse would hold digoxin if an apical heart rate falls below which number? Answer: 70 beats/min Question: A health care provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of acute digoxin toxicity? Answer: Vomiting Question: When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin? Answer: yellow vision Question: Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity? Answer: Cardiac dysrhythmias Question: A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide Answer: "The medication may need to be discontinued. Come to the clinic this afternoon." Question: Digoxin is prescribed for a client. Which therapeutic effect of digoxin would the nurse expect? Answer: Increased contractile force of the myocardium Question: A client who has been diagnosed with a myocardial infarction receives digoxin, fluoxetine, morphine, and docusate sodium. Which medication would the nurse identify as a risk factor for straining due to constipation? Answer: Morphine