,1. A patient with chronic heart failure presents with shortness of breath, crackles auscultated in
the lung bases, and 3+ pitting edema in the lower extremities. Which nursing intervention
should be implemented first?
A) Encourage the patient to ambulate
B) Administer the prescribed diuretic (furosemide)
C) Restrict the patient's fluid intake to 1 L/day
D) Provide a high-sodium diet according to the care plan
Correct Answer: Administer the prescribed diuretic (furosemide)
Rationale: Crackles and edema indicate significant fluid overload, requiring rapid reduction of
preload in acute decompensated heart failure. Administering a loop diuretic is the priority
intervention to reduce congestion and improve symptoms . Fluid restriction is important but not
the immediate priority, and a high-sodium diet would worsen fluid retention .
2. A nurse is providing discharge teaching to a patient with heart failure. Which patient
statement indicates a correct understanding of dietary modifications?
A) "I should limit my daily fluid intake to 4 liters."
B) "I need to avoid canned soups and frozen dinners."
C) "Adding extra salt to my food will help with fluid balance."
D) "Reading food labels for sodium content is not necessary."
Correct Answer: "I need to avoid canned soups and frozen dinners."
Rationale: Processed foods like canned soups and frozen dinners are typically high in sodium
and should be avoided . Heart failure patients must follow a low-sodium diet (usually <2,000
mg/day) to prevent fluid retention. Patients should read labels and limit high-sodium items .
,3. A nurse is monitoring a patient with a pulmonary embolism. Which assessment finding
requires the most immediate intervention?
A) Clear lung fields bilaterally
B) Heart rate of 104 beats/minute
C) Oxygen saturation of 88% on room air
D) Blood pressure of 118/76 mmHg
Correct Answer: Oxygen saturation of 88% on room air
Rationale: Hypoxemia (SpO₂ 88%) indicates impaired gas exchange and places the patient at risk
for respiratory failure or right-sided heart failure . Immediate oxygen therapy is required. PE
often presents with clear lung fields despite severe hypoxemia .
4. A nurse is assessing a patient with emphysema. Which physical characteristic is most
commonly associated with this condition?
A) Productive cough
B) Barrel chest
C) Cyanosis
D) Clubbing of fingers
Correct Answer: Barrel chest
Rationale: Barrel chest results from air trapping and hyperinflation in emphysema . Productive
cough is more typical of chronic bronchitis, not emphysema . Cyanosis and clubbing can occur
but are not the most common associated characteristics .
5. The nurse is assessing a patient who frequently coughs after eating or drinking. How should
the nurse best follow up this assessment finding?
, A) Obtain a sputum sample
B) Perform a swallowing assessment
C) Inspect the patient's tongue and mouth
D) Assess the patient's nutritional status
Correct Answer: Perform a swallowing assessment
Rationale: Coughing after food intake may indicate aspiration of material into the
tracheobronchial tree; a swallowing assessment is thus indicated . Obtaining a sputum sample is
relevant in cases of suspected infection but not the priority .
6. A nurse is caring for a patient who has just returned to the unit after a colon resection. The
patient is showing signs of hypoxia. The nurse knows that this is most likely caused by what?
A) Nitrogen narcosis
B) Infection
C) Impaired diffusion
D) Shunting
Correct Answer: Shunting
Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal
surgery and most types of respiratory failure . Impairment of normal diffusion is a less common
cause .
7. A patient asks the nurse why an infection in her upper respiratory system is affecting the
clarity of her speech. Which structure serves as the patient's resonating chamber in speech?
A) Trachea
B) Pharynx
the lung bases, and 3+ pitting edema in the lower extremities. Which nursing intervention
should be implemented first?
A) Encourage the patient to ambulate
B) Administer the prescribed diuretic (furosemide)
C) Restrict the patient's fluid intake to 1 L/day
D) Provide a high-sodium diet according to the care plan
Correct Answer: Administer the prescribed diuretic (furosemide)
Rationale: Crackles and edema indicate significant fluid overload, requiring rapid reduction of
preload in acute decompensated heart failure. Administering a loop diuretic is the priority
intervention to reduce congestion and improve symptoms . Fluid restriction is important but not
the immediate priority, and a high-sodium diet would worsen fluid retention .
2. A nurse is providing discharge teaching to a patient with heart failure. Which patient
statement indicates a correct understanding of dietary modifications?
A) "I should limit my daily fluid intake to 4 liters."
B) "I need to avoid canned soups and frozen dinners."
C) "Adding extra salt to my food will help with fluid balance."
D) "Reading food labels for sodium content is not necessary."
Correct Answer: "I need to avoid canned soups and frozen dinners."
Rationale: Processed foods like canned soups and frozen dinners are typically high in sodium
and should be avoided . Heart failure patients must follow a low-sodium diet (usually <2,000
mg/day) to prevent fluid retention. Patients should read labels and limit high-sodium items .
,3. A nurse is monitoring a patient with a pulmonary embolism. Which assessment finding
requires the most immediate intervention?
A) Clear lung fields bilaterally
B) Heart rate of 104 beats/minute
C) Oxygen saturation of 88% on room air
D) Blood pressure of 118/76 mmHg
Correct Answer: Oxygen saturation of 88% on room air
Rationale: Hypoxemia (SpO₂ 88%) indicates impaired gas exchange and places the patient at risk
for respiratory failure or right-sided heart failure . Immediate oxygen therapy is required. PE
often presents with clear lung fields despite severe hypoxemia .
4. A nurse is assessing a patient with emphysema. Which physical characteristic is most
commonly associated with this condition?
A) Productive cough
B) Barrel chest
C) Cyanosis
D) Clubbing of fingers
Correct Answer: Barrel chest
Rationale: Barrel chest results from air trapping and hyperinflation in emphysema . Productive
cough is more typical of chronic bronchitis, not emphysema . Cyanosis and clubbing can occur
but are not the most common associated characteristics .
5. The nurse is assessing a patient who frequently coughs after eating or drinking. How should
the nurse best follow up this assessment finding?
, A) Obtain a sputum sample
B) Perform a swallowing assessment
C) Inspect the patient's tongue and mouth
D) Assess the patient's nutritional status
Correct Answer: Perform a swallowing assessment
Rationale: Coughing after food intake may indicate aspiration of material into the
tracheobronchial tree; a swallowing assessment is thus indicated . Obtaining a sputum sample is
relevant in cases of suspected infection but not the priority .
6. A nurse is caring for a patient who has just returned to the unit after a colon resection. The
patient is showing signs of hypoxia. The nurse knows that this is most likely caused by what?
A) Nitrogen narcosis
B) Infection
C) Impaired diffusion
D) Shunting
Correct Answer: Shunting
Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal
surgery and most types of respiratory failure . Impairment of normal diffusion is a less common
cause .
7. A patient asks the nurse why an infection in her upper respiratory system is affecting the
clarity of her speech. Which structure serves as the patient's resonating chamber in speech?
A) Trachea
B) Pharynx
