NUR 329: Exam 1|Verified Questions
And Answers.
The client is admitted to the telemetry unit diagnosed with acute
exacerbation of congestive heart failure (CHF). Which signs/symptoms
would the nurse expect to find when assessing this client?
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white sputum and crackles that clear with cough.
3. The client sleeping with no pillow and eupnea.
4. Radial pulse rate of 90 and capillary refill time <3 seconds. ~CORRECT
ANSWER~✓✓1. Apical pulse rate of 110 and 4+ pitting edema of feet.
The nurse is developing a nursing care plan for a client diagnosed with
congestive heart failure. A nursing diagnosis of "decreased cardiac output
related to inability of the heart to pump effectively" is written. Which short-
term goal would be best for the client? The client will:
1. Be able to ambulate in the hall by date of discharge.
2. Have an audible S1 and S2 with no S3 heard by end of shift.
3. Turn, cough, and deep breathe every two (2) hours.
,4. Have a pulse oximeter reading of 98% by day two (2) of care.
~CORRECT ANSWER~✓✓2. Have an audible S1 and S2 with no S3 heard
by end of shift.
The nurse is developing a discharge-teaching plan for the client diagnosed
with congestive heart failure. Which interventions should be included in
the plan? Select all that apply.
1. Notify health-care provider of a weight gain of more than one (1) pound
in a week.
2. Teach client how to count the radial pulse when taking digoxin, a cardiac
glycoside.
3. Instruct client to remove the saltshaker from the dinner table.
4. Encourage client to monitor urine output for change in color to become
dark.
5. Discuss the importance of taking the loop diuretic furosemide at
bedtime. ~CORRECT ANSWER~✓✓2. Teach client how to count the radial
pulse when taking digoxin, a cardiac glycoside.
3. Instruct client to remove the saltshaker from the dinner table.
The nurse enters the room of the client diagnosed with congestive heart
failure. The client is lying in bed gasping for breath, is cool and clammy,
and has buccal cyanosis. Which intervention would the nurse implement
first?
,1. Sponge the client's forehead.
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting position. ~CORRECT ANSWER~✓✓4. Assist
the client to a sitting position.
The nurse is assessing the client diagnosed with congestive heart failure.
Which signs/symptoms would indicate that the medical treatment has been
effective?
1. The client's peripheral pitting edema has gone from 3+ to 4+.
2. The client is able to take the radial pulse accurately.
3. The client is able to perform ADLs without dyspnea.
4. The client has minimal jugular vein distention. ~CORRECT
ANSWER~✓✓3. The client is able to perform ADLs without dyspnea.
The nurse is assessing the client diagnosed with congestive heart failure.
Which laboratory data would indicate that the client is in severe congestive
heart failure?
1. An elevated B-type natriuretic peptide (BNP).
, 2. An elevated creatine kinase (CK-MB).
3. A positive D-dimer.
4. A positive ventilation/perfusion (V/Q) scan. ~CORRECT ANSWER~✓✓1.
An elevated B-type natriuretic peptide (BNP).
The health-care provider has ordered an angiotensin-converting enzyme
(ACE) inhibitor for the client diagnosed with congestive heart failure.
Which discharge instructions should the nurse include?
1. Instruct the client to take a cough suppressant if a cough develops.
2. Teach the client how to prevent orthostatic hypotension.
3. Encourage the client to eat bananas to increase potassium level.
4. Explain the importance of taking the medication with food. ~CORRECT
ANSWER~✓✓2. Teach the client how to prevent orthostatic hypotension.
The nurse on the telemetry unit has just received the a.m. shift report.
Which client should the nurse assess first?
1. The client diagnosed with myocardial infarction who has an audible S3
heart
sound.
2. The client diagnosed with congestive heart failure who has 4+ sacral
pitting
And Answers.
The client is admitted to the telemetry unit diagnosed with acute
exacerbation of congestive heart failure (CHF). Which signs/symptoms
would the nurse expect to find when assessing this client?
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white sputum and crackles that clear with cough.
3. The client sleeping with no pillow and eupnea.
4. Radial pulse rate of 90 and capillary refill time <3 seconds. ~CORRECT
ANSWER~✓✓1. Apical pulse rate of 110 and 4+ pitting edema of feet.
The nurse is developing a nursing care plan for a client diagnosed with
congestive heart failure. A nursing diagnosis of "decreased cardiac output
related to inability of the heart to pump effectively" is written. Which short-
term goal would be best for the client? The client will:
1. Be able to ambulate in the hall by date of discharge.
2. Have an audible S1 and S2 with no S3 heard by end of shift.
3. Turn, cough, and deep breathe every two (2) hours.
,4. Have a pulse oximeter reading of 98% by day two (2) of care.
~CORRECT ANSWER~✓✓2. Have an audible S1 and S2 with no S3 heard
by end of shift.
The nurse is developing a discharge-teaching plan for the client diagnosed
with congestive heart failure. Which interventions should be included in
the plan? Select all that apply.
1. Notify health-care provider of a weight gain of more than one (1) pound
in a week.
2. Teach client how to count the radial pulse when taking digoxin, a cardiac
glycoside.
3. Instruct client to remove the saltshaker from the dinner table.
4. Encourage client to monitor urine output for change in color to become
dark.
5. Discuss the importance of taking the loop diuretic furosemide at
bedtime. ~CORRECT ANSWER~✓✓2. Teach client how to count the radial
pulse when taking digoxin, a cardiac glycoside.
3. Instruct client to remove the saltshaker from the dinner table.
The nurse enters the room of the client diagnosed with congestive heart
failure. The client is lying in bed gasping for breath, is cool and clammy,
and has buccal cyanosis. Which intervention would the nurse implement
first?
,1. Sponge the client's forehead.
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting position. ~CORRECT ANSWER~✓✓4. Assist
the client to a sitting position.
The nurse is assessing the client diagnosed with congestive heart failure.
Which signs/symptoms would indicate that the medical treatment has been
effective?
1. The client's peripheral pitting edema has gone from 3+ to 4+.
2. The client is able to take the radial pulse accurately.
3. The client is able to perform ADLs without dyspnea.
4. The client has minimal jugular vein distention. ~CORRECT
ANSWER~✓✓3. The client is able to perform ADLs without dyspnea.
The nurse is assessing the client diagnosed with congestive heart failure.
Which laboratory data would indicate that the client is in severe congestive
heart failure?
1. An elevated B-type natriuretic peptide (BNP).
, 2. An elevated creatine kinase (CK-MB).
3. A positive D-dimer.
4. A positive ventilation/perfusion (V/Q) scan. ~CORRECT ANSWER~✓✓1.
An elevated B-type natriuretic peptide (BNP).
The health-care provider has ordered an angiotensin-converting enzyme
(ACE) inhibitor for the client diagnosed with congestive heart failure.
Which discharge instructions should the nurse include?
1. Instruct the client to take a cough suppressant if a cough develops.
2. Teach the client how to prevent orthostatic hypotension.
3. Encourage the client to eat bananas to increase potassium level.
4. Explain the importance of taking the medication with food. ~CORRECT
ANSWER~✓✓2. Teach the client how to prevent orthostatic hypotension.
The nurse on the telemetry unit has just received the a.m. shift report.
Which client should the nurse assess first?
1. The client diagnosed with myocardial infarction who has an audible S3
heart
sound.
2. The client diagnosed with congestive heart failure who has 4+ sacral
pitting
