NUR 242 MED SURG EXAM 3 LATEST
2024-2025 ACTUAL EXAM 180
QUESTIONS AND CORRECT
DETAILED ANSWERS | ALREADY
GRADED A+
/. 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
/.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
/.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
/.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
/.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.
/.Which treatment would the nurse anticipate when caring for an infant with heart
failure? - Answer-✅Medications that are prescribed for both children and adults
/.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
,/.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
/.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
/.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
/.Which assessment finding is a late sign of heart failure? - Answer-✅Peripheral edema
/.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
/.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
/.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
/.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
/.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)
/.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
/.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
/.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.
/.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
/.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
/.Which intervention would the nurse implement for a 4-month-old infant with tetralogy of
Fallot and heart failure? - Answer-✅Providing small, frequent feedings
/.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
/.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
/.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
/.Which sign would indicate possible heart failure in a client with heart disease in the
immediate postpartum period? - Answer-✅Tachypnea
/.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
/.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
2024-2025 ACTUAL EXAM 180
QUESTIONS AND CORRECT
DETAILED ANSWERS | ALREADY
GRADED A+
/. 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
/.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
/.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
/.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
/.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.
/.Which treatment would the nurse anticipate when caring for an infant with heart
failure? - Answer-✅Medications that are prescribed for both children and adults
/.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
,/.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
/.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
/.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
/.Which assessment finding is a late sign of heart failure? - Answer-✅Peripheral edema
/.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
/.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
/.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
/.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
/.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)
/.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
/.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
/.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.
/.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
/.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
/.Which intervention would the nurse implement for a 4-month-old infant with tetralogy of
Fallot and heart failure? - Answer-✅Providing small, frequent feedings
/.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
/.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
/.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
/.Which sign would indicate possible heart failure in a client with heart disease in the
immediate postpartum period? - Answer-✅Tachypnea
/.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
/.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
