1
Med Surg Success Test 1| 2025 most
recent update|COMPLETE QUESTIONS
AND VERIFIED ANSWERS|GET IT 100%
ACCURATE |SCORE A+
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. - (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. - (ANSWER)2.
Have an audible S1 and S2 with no S3 heard by end of shift.
,2
Reason: Audible S1 & S2 are normal for a heart with adequate output, an audible
S3 may indicate left ventricular heart failure
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. -
(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.
#4 is not a choice because the patient should be on a diuretic and urine should be
more frequent & lighter
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.
,3
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting position. - (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. - (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. - (ANSWER)1. An elevated B-type
natriuretic peptide (BNP).
, 4
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. - (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
edema.
3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
4. The client with chronic renal failure who has an elevated creatinine level. -
(ANSWER)1. The client diagnosed with myocardial infarction who has an audible
S3 heart
sound.
An audible S3 indicates left ventricular heart failure and the nurse must assess
this client first because it is an emergency situation
Med Surg Success Test 1| 2025 most
recent update|COMPLETE QUESTIONS
AND VERIFIED ANSWERS|GET IT 100%
ACCURATE |SCORE A+
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. - (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. - (ANSWER)2.
Have an audible S1 and S2 with no S3 heard by end of shift.
,2
Reason: Audible S1 & S2 are normal for a heart with adequate output, an audible
S3 may indicate left ventricular heart failure
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. -
(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.
#4 is not a choice because the patient should be on a diuretic and urine should be
more frequent & lighter
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.
,3
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting position. - (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. - (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. - (ANSWER)1. An elevated B-type
natriuretic peptide (BNP).
, 4
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. - (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
edema.
3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
4. The client with chronic renal failure who has an elevated creatinine level. -
(ANSWER)1. The client diagnosed with myocardial infarction who has an audible
S3 heart
sound.
An audible S3 indicates left ventricular heart failure and the nurse must assess
this client first because it is an emergency situation
