Nur 114 Test 3 Actual Test Questions And Answers
With Verified Solutions
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse
expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight)
response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing
ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will
drop because of decreased HR.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the
nurse to the occurrence of left-sided heart failure?
a. I get short of breath when I climb stairs.
b. I see halos floating around my head.
c. I have trouble remembering things.
d. I have lost weight over the past month. ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as
stairclimbing. The other findings are not specific to early occurrence of heart failure.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by
the client should alert the nurse to the presence of edema with right-sided heart failure?
a. I wake up to go to the bathroom at night.
b. My shoes fit tighter by the end of the day.
c. I seem to be feeling more anxious lately.
d. I drink at least eight glasses of water a day. ANS: B
, Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The
nurseshould note whether the client feels that his or her shoes or rings are tight, and should observe, when
present,an indentation around the leg where the socks end. The other answers do not describe edema.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that
the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as left pedal pulse of +1/4. ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. Thepulse
may be faint because of edema. The left pulse should be compared with the right, and pulses should
becompared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis)
andtemperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular
assessmentdata are acquired, the primary health care provider should be notified. Simply documenting the
findings isinappropriate. The leg should be positioned below the level of the heart or dangling to increase
blood flow tothe distal portion of the leg. Increasing intravenous fluids will not address the clients problem.
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on S3 heart
tones heard?
a. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the clients medications. ANS: B
The sound heard is an atrial gallop S3. An atrial gallop may be heard in older clients because of a stiffened
ventricle. The nurse should document the finding, but no other intervention is needed at this time.
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should
the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
a. Location A
b. Location B
c. Location C
d. Location D ANS: A
With Verified Solutions
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse
expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight)
response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing
ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will
drop because of decreased HR.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the
nurse to the occurrence of left-sided heart failure?
a. I get short of breath when I climb stairs.
b. I see halos floating around my head.
c. I have trouble remembering things.
d. I have lost weight over the past month. ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as
stairclimbing. The other findings are not specific to early occurrence of heart failure.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by
the client should alert the nurse to the presence of edema with right-sided heart failure?
a. I wake up to go to the bathroom at night.
b. My shoes fit tighter by the end of the day.
c. I seem to be feeling more anxious lately.
d. I drink at least eight glasses of water a day. ANS: B
, Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The
nurseshould note whether the client feels that his or her shoes or rings are tight, and should observe, when
present,an indentation around the leg where the socks end. The other answers do not describe edema.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that
the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as left pedal pulse of +1/4. ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. Thepulse
may be faint because of edema. The left pulse should be compared with the right, and pulses should
becompared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis)
andtemperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular
assessmentdata are acquired, the primary health care provider should be notified. Simply documenting the
findings isinappropriate. The leg should be positioned below the level of the heart or dangling to increase
blood flow tothe distal portion of the leg. Increasing intravenous fluids will not address the clients problem.
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on S3 heart
tones heard?
a. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the clients medications. ANS: B
The sound heard is an atrial gallop S3. An atrial gallop may be heard in older clients because of a stiffened
ventricle. The nurse should document the finding, but no other intervention is needed at this time.
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should
the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
a. Location A
b. Location B
c. Location C
d. Location D ANS: A
