GNRS 555 - Exam 3 Questions With Complete Solutions
-Mr. Cameron indicated that his pain is in the
middle of his chest and radiates to his left arm. It is
about 6/10. He added that this was not the first
time he had this pain. He said that the pain usually
starts a few minutes after gardening or climbing
stairs and is relieved by rest. Angina is suspected.
-What type of angina did Mr. Cameron just
describe? Correct Answers Stable
A patient has recently started taking oral digoxin
(Lanoxin) in addition to furosemide (Lasix) and
captopril (Capoten) for control of heart failure.
Which assessment finding by the home health
nurse is most important to communicate to the
health care provider?
A. Presence of 1 to 2+ edema in the feet and
ankles
B. Liver is palpable 2 cm below the ribs on the right
side.
C. Serum potassium level is 3.0 mEq/L after 1 week
of therapy
D. Weight increase from 120 pounds to 122 pounds
over 3 days Correct Answers C. Serum potassium
level is 3.0 mEq/L after 1 week of therapy
A patient in the intensive care unit with acute
decompensated heart failure (ADHF) complains of
severe dyspnea and is anxious, tachypneic, and
,tachycardic. All these medications have been
ordered for the patient. The first action by the
nurse will be to
A. Give IV diazepam (Valium) 2.5 mg.
B. Administer IV morphine sulfate 2 mg.
C. Increase nitroglycerin (Tridil) infusion by 5
mcg/min.
D. Increase dopamine (Intropin) infusion by 2
mcg/kg/min. Correct Answers B. Administer IV
morphine sulfate 2 mg.
A patient who has chronic heart failure tells the
nurse, "I felt fine when I went to bed, but I woke up
in the middle of the night feeling like I was
suffocating!" The nurse will document this
assessment information as
A. Pulsus alternans.
B. Two-pillow orthopnea.
C. Acute bilateral pleural effusion.
D. Paroxysmal nocturnal dyspnea. Correct
Answers D. Paroxysmal nocturnal dyspnea.
A patient who is receiving dobutamine (Dobutrex)
for the treatment of acute decompensated heart
failure (ADHF) has the following nursing actions
included in the plan of care. Which action will be
best for the RN to delegate to an experienced
LPN/LVN?
A. Evaluate the IV insertion site for extravasation.
,B. Document the patient's BP and heart rate every
hour.
C. Adjust the rate to keep the systolic BP >90 mm
Hg.
D. Teach the patient the reasons for remaining on
bed rest. Correct Answers B. Document the
patient's BP and heart rate every hour.
A patient with a history of chronic heart failure is
admitted to the emergency department (ED) with
severe dyspnea and a dry, hacking cough. Which
action should the nurse take first?
A. Palpate the abdomen.
B. Assess the orientation.
C. Check the capillary refill.
D. Auscultate the lung sounds. Correct Answers D.
Auscultate the lung sounds.
A patient with heart failure has a new order for
captopril (Capoten) 12.5 mg PO. After
administering the first dose and teaching the
patient about captopril, which statement by the
patient indicates that teaching has been effective?
A. "I will call for help when I need to get up to use
the bathroom."
B. "I will be sure to take the medication after eating
something."
C. "I will need to include more high-potassium
foods in my diet."
, D. "I will expect to feel more short of breath for the
next few days." Correct Answers A. "I will call for
help when I need to get up to use the bathroom."
After receiving change-of-shift report, which of
these patients admitted with heart failure should
the nurse assess first?
A. A patient who is receiving IV nesiritide
(Natrecor) and has a blood pressure (BP) of 100/56
B. A patient who is cool and clammy, with new-
onset confusion and restlessness
C. A patient who had dizziness after receiving the
first dose of captopril (Capoten)
D. A patient who has crackles in both posterior lung
bases and is receiving oxygen Correct Answers B.
A patient who is cool and clammy, with new-onset
confusion and restlessness
After you finished teaching Mr. Cameron about
sublingual nitroglycerin (Nitrostat), which
statement indicates that the teaching has been
effective?
A. "I will help slow down the progress of the plaque
formation by taking nitroglycerin."
B. "I will call an ambulance if I still have pain 5
minutes after taking the nitroglycerin. I can repeat
every 5 minutes for a maximum of 3 doses before
calling EMS"
C. "I can only take the nitroglycerin if I start to
have chest pain."
-Mr. Cameron indicated that his pain is in the
middle of his chest and radiates to his left arm. It is
about 6/10. He added that this was not the first
time he had this pain. He said that the pain usually
starts a few minutes after gardening or climbing
stairs and is relieved by rest. Angina is suspected.
-What type of angina did Mr. Cameron just
describe? Correct Answers Stable
A patient has recently started taking oral digoxin
(Lanoxin) in addition to furosemide (Lasix) and
captopril (Capoten) for control of heart failure.
Which assessment finding by the home health
nurse is most important to communicate to the
health care provider?
A. Presence of 1 to 2+ edema in the feet and
ankles
B. Liver is palpable 2 cm below the ribs on the right
side.
C. Serum potassium level is 3.0 mEq/L after 1 week
of therapy
D. Weight increase from 120 pounds to 122 pounds
over 3 days Correct Answers C. Serum potassium
level is 3.0 mEq/L after 1 week of therapy
A patient in the intensive care unit with acute
decompensated heart failure (ADHF) complains of
severe dyspnea and is anxious, tachypneic, and
,tachycardic. All these medications have been
ordered for the patient. The first action by the
nurse will be to
A. Give IV diazepam (Valium) 2.5 mg.
B. Administer IV morphine sulfate 2 mg.
C. Increase nitroglycerin (Tridil) infusion by 5
mcg/min.
D. Increase dopamine (Intropin) infusion by 2
mcg/kg/min. Correct Answers B. Administer IV
morphine sulfate 2 mg.
A patient who has chronic heart failure tells the
nurse, "I felt fine when I went to bed, but I woke up
in the middle of the night feeling like I was
suffocating!" The nurse will document this
assessment information as
A. Pulsus alternans.
B. Two-pillow orthopnea.
C. Acute bilateral pleural effusion.
D. Paroxysmal nocturnal dyspnea. Correct
Answers D. Paroxysmal nocturnal dyspnea.
A patient who is receiving dobutamine (Dobutrex)
for the treatment of acute decompensated heart
failure (ADHF) has the following nursing actions
included in the plan of care. Which action will be
best for the RN to delegate to an experienced
LPN/LVN?
A. Evaluate the IV insertion site for extravasation.
,B. Document the patient's BP and heart rate every
hour.
C. Adjust the rate to keep the systolic BP >90 mm
Hg.
D. Teach the patient the reasons for remaining on
bed rest. Correct Answers B. Document the
patient's BP and heart rate every hour.
A patient with a history of chronic heart failure is
admitted to the emergency department (ED) with
severe dyspnea and a dry, hacking cough. Which
action should the nurse take first?
A. Palpate the abdomen.
B. Assess the orientation.
C. Check the capillary refill.
D. Auscultate the lung sounds. Correct Answers D.
Auscultate the lung sounds.
A patient with heart failure has a new order for
captopril (Capoten) 12.5 mg PO. After
administering the first dose and teaching the
patient about captopril, which statement by the
patient indicates that teaching has been effective?
A. "I will call for help when I need to get up to use
the bathroom."
B. "I will be sure to take the medication after eating
something."
C. "I will need to include more high-potassium
foods in my diet."
, D. "I will expect to feel more short of breath for the
next few days." Correct Answers A. "I will call for
help when I need to get up to use the bathroom."
After receiving change-of-shift report, which of
these patients admitted with heart failure should
the nurse assess first?
A. A patient who is receiving IV nesiritide
(Natrecor) and has a blood pressure (BP) of 100/56
B. A patient who is cool and clammy, with new-
onset confusion and restlessness
C. A patient who had dizziness after receiving the
first dose of captopril (Capoten)
D. A patient who has crackles in both posterior lung
bases and is receiving oxygen Correct Answers B.
A patient who is cool and clammy, with new-onset
confusion and restlessness
After you finished teaching Mr. Cameron about
sublingual nitroglycerin (Nitrostat), which
statement indicates that the teaching has been
effective?
A. "I will help slow down the progress of the plaque
formation by taking nitroglycerin."
B. "I will call an ambulance if I still have pain 5
minutes after taking the nitroglycerin. I can repeat
every 5 minutes for a maximum of 3 doses before
calling EMS"
C. "I can only take the nitroglycerin if I start to
have chest pain."
