nur 103- exam 2 (Answered) 87
Questions and Correct Answers, 100%
Correct. Latest 2024/2025.
what is a type of nursing education program that is conducted in junior and community colleges that
nominally 2 years in length?
a. diploma program
b. baccalaureate program
c. associate degree program
d. professional nursing program
c
The nurse in a skilled nursing facility is caring for an 80-year-old patient who develops
a productive cough with pink, frothy sputum. Which independent interventions should the nurse
implement immediately? (Select all that apply.)
a. Limit the patient's activity.
b. Administer morphine.
c. Administer lasix.
d. Place the patient in high Fowler position.
e. Weigh the patient daily.
ANS: A, D
Acute pulmonary edema (acute left ventricular failure) is a medical emergency that must be treated
promptly. The patient with this condition has severe dyspnea; a cough productive of frothy, pink-
tinged
sputum; tachycardia; and moist, bubbling respirations with cyanosis. Nursing interventions for acute
pulmonary edema include placing the patient in high Fowler position to relieve the dyspnea;
administering oxygen, diuretics, morphine, and other prescribed drugs; limiting and monitoring
activity;
and assessing cardiopulmonary status. Limiting activity and placing the patient in high Fowler do not
require a physician's order and should be implemented immediately. Acute pulmonary edema is a
medical emergency, and activity necessary to obtain a daily weight is not indicated at this time.
Administering morphine and diuretics are dependent nursing interventions.
The nurse is educating a patient about cardiomyopathy. The nurse includes information
that which circumstance(s) may increase risk for cardiomyopathy? (Select all that apply.)
a. Systemic hypertension
b. Chronic excessive alcohol consumption
c. Pregnancy
d. Diabetes
e. Systemic infection
ANS: A, B, C, E
Cardiomyopathy is a group of disorders that result in enlargement of the heart and subsequent
inefficient
,pumping action. Risk factors include systemic hypertension, chronic alcohol consumption,
pregnancy,
and certain systemic infections. Diabetes is not considered a risk factor for cardiomyopathy.
Which factor(s) is/are potential causative agents for arrhythmias? (Select all that
apply.)
a. Hyperkalemia
b. Valvular prolapse
c. Infarct damage
d. Properly functioning sinoatrial (SA) node
e. Excess fluid
ANS: A, B, C, E
Electrolyte imbalances, especially a high-potassium level, valvular prolapse, heart damage after a
heart
attack, and fluid overload are all potential causative factors for abnormal heart rhythms. A properly
functioning SA node results in normal sinus rhythm.
Which statement(s) accurately describe(s) characteristics of normal sinus rhythm
(NSR)? (Select all that apply.)
a. One atrial contraction (P wave)
b. One ventricular contraction (QRS complex)
c. One T wave
d. Heart rate 60 to 100
e. P wave immediately follows the QRS complex
ANS: A, B, C, D
The P wave precedes the QRS complex. All other options are seen in NSR.
The nurse is performing an initial assessment on a new patient with suspected right-
sided heart failure. Which finding(s) is/are consistent with the patient's potential diagnosis? (Select
all that apply.)
a. Clammy skin
b. Splenomegaly
c. Abdominal distention
d. Wheezing
e. Dyspnea
ANS: B, C, E
Signs and symptoms of right-sided CHF include fatigue, peripheral edema, gastrointestinal
congestion
and abdominal distention, ascites with liver congestion, splenomegaly, and dyspnea. Clammy skin
and
wheezing are symptoms of left-sided CHF.
The nurse is caring for a 60-year-old African American patient with hypertension. The
patient is obese and a smoker. Which modifiable risk factors place this patient at an increased risk
for heart disease? (Select all that apply.)
a. Age
b. Race
c. Hypertension
, d. Obesity
e. Smoking
cde
Modifiable risk factors that increase the patient's risk of heart disease include hypertension, obesity,
and
cigarette smoking. The patient could lessen his risk by strictly controlling blood pressure, losing
weight
with diet and exercise, and implementing a smoking cessation plan. Age and race are nonmodifiable
risk
factors for heart disease.
The home health nurse is caring for a patient with congestive heart failure (CHF).
Which assessment finding should the nurse report immediately to the physician?
a. Moderate shortness of breath after walking down the hall
b. A 3 pound weight gain over the course of a week
c. Heart rate of 104 beats/min after ambulating to the bathroom
d. Increase in urinary output to 50 mL in the last hour
B
A weight gain without an increase in caloric intake is indicative of fluid retention, which is an
indication
of worsening heart failure. Moderate shortness of breath after exercise and a mild increase in heart
rate
after activity are expected. A decrease in urinary output would be of concern.
The nurse is caring for several patients on a cardiac care unit. Which patient is most
likely to have aortic stenosis?
a. 35-year-old with a history of Raynaud disease
b. 63-year-old with uncontrolled diabetes
c. 73-year-old with a history of hypertension
d. 86-year-old with a history of atherosclerosis
ANS: D
The older 86-year-old patient with atherosclerosis is most likely to have degenerative calcification of
the
valve. Risk for aortic stenosis increases with age, and congenital valve malformations and rheumatic
fever
are causes in younger patients.
The nurse is caring for a patient who is taking digitalis. The patient complains of
increased thirst, and the nurse observes dry mucous membranes. Which additional finding warrants
the nurse's immediate attention?
a. Sudden, sharp knee pain
b. Blurred vision
c. Epistaxis
d. Chills
ANS: B
Blurred vision, halos around lights, nausea, vomiting and diarrhea, and fatigue are all indicators of
toxicity to digitalis. Assessment is especially important for the dehydrated patient because of the
Questions and Correct Answers, 100%
Correct. Latest 2024/2025.
what is a type of nursing education program that is conducted in junior and community colleges that
nominally 2 years in length?
a. diploma program
b. baccalaureate program
c. associate degree program
d. professional nursing program
c
The nurse in a skilled nursing facility is caring for an 80-year-old patient who develops
a productive cough with pink, frothy sputum. Which independent interventions should the nurse
implement immediately? (Select all that apply.)
a. Limit the patient's activity.
b. Administer morphine.
c. Administer lasix.
d. Place the patient in high Fowler position.
e. Weigh the patient daily.
ANS: A, D
Acute pulmonary edema (acute left ventricular failure) is a medical emergency that must be treated
promptly. The patient with this condition has severe dyspnea; a cough productive of frothy, pink-
tinged
sputum; tachycardia; and moist, bubbling respirations with cyanosis. Nursing interventions for acute
pulmonary edema include placing the patient in high Fowler position to relieve the dyspnea;
administering oxygen, diuretics, morphine, and other prescribed drugs; limiting and monitoring
activity;
and assessing cardiopulmonary status. Limiting activity and placing the patient in high Fowler do not
require a physician's order and should be implemented immediately. Acute pulmonary edema is a
medical emergency, and activity necessary to obtain a daily weight is not indicated at this time.
Administering morphine and diuretics are dependent nursing interventions.
The nurse is educating a patient about cardiomyopathy. The nurse includes information
that which circumstance(s) may increase risk for cardiomyopathy? (Select all that apply.)
a. Systemic hypertension
b. Chronic excessive alcohol consumption
c. Pregnancy
d. Diabetes
e. Systemic infection
ANS: A, B, C, E
Cardiomyopathy is a group of disorders that result in enlargement of the heart and subsequent
inefficient
,pumping action. Risk factors include systemic hypertension, chronic alcohol consumption,
pregnancy,
and certain systemic infections. Diabetes is not considered a risk factor for cardiomyopathy.
Which factor(s) is/are potential causative agents for arrhythmias? (Select all that
apply.)
a. Hyperkalemia
b. Valvular prolapse
c. Infarct damage
d. Properly functioning sinoatrial (SA) node
e. Excess fluid
ANS: A, B, C, E
Electrolyte imbalances, especially a high-potassium level, valvular prolapse, heart damage after a
heart
attack, and fluid overload are all potential causative factors for abnormal heart rhythms. A properly
functioning SA node results in normal sinus rhythm.
Which statement(s) accurately describe(s) characteristics of normal sinus rhythm
(NSR)? (Select all that apply.)
a. One atrial contraction (P wave)
b. One ventricular contraction (QRS complex)
c. One T wave
d. Heart rate 60 to 100
e. P wave immediately follows the QRS complex
ANS: A, B, C, D
The P wave precedes the QRS complex. All other options are seen in NSR.
The nurse is performing an initial assessment on a new patient with suspected right-
sided heart failure. Which finding(s) is/are consistent with the patient's potential diagnosis? (Select
all that apply.)
a. Clammy skin
b. Splenomegaly
c. Abdominal distention
d. Wheezing
e. Dyspnea
ANS: B, C, E
Signs and symptoms of right-sided CHF include fatigue, peripheral edema, gastrointestinal
congestion
and abdominal distention, ascites with liver congestion, splenomegaly, and dyspnea. Clammy skin
and
wheezing are symptoms of left-sided CHF.
The nurse is caring for a 60-year-old African American patient with hypertension. The
patient is obese and a smoker. Which modifiable risk factors place this patient at an increased risk
for heart disease? (Select all that apply.)
a. Age
b. Race
c. Hypertension
, d. Obesity
e. Smoking
cde
Modifiable risk factors that increase the patient's risk of heart disease include hypertension, obesity,
and
cigarette smoking. The patient could lessen his risk by strictly controlling blood pressure, losing
weight
with diet and exercise, and implementing a smoking cessation plan. Age and race are nonmodifiable
risk
factors for heart disease.
The home health nurse is caring for a patient with congestive heart failure (CHF).
Which assessment finding should the nurse report immediately to the physician?
a. Moderate shortness of breath after walking down the hall
b. A 3 pound weight gain over the course of a week
c. Heart rate of 104 beats/min after ambulating to the bathroom
d. Increase in urinary output to 50 mL in the last hour
B
A weight gain without an increase in caloric intake is indicative of fluid retention, which is an
indication
of worsening heart failure. Moderate shortness of breath after exercise and a mild increase in heart
rate
after activity are expected. A decrease in urinary output would be of concern.
The nurse is caring for several patients on a cardiac care unit. Which patient is most
likely to have aortic stenosis?
a. 35-year-old with a history of Raynaud disease
b. 63-year-old with uncontrolled diabetes
c. 73-year-old with a history of hypertension
d. 86-year-old with a history of atherosclerosis
ANS: D
The older 86-year-old patient with atherosclerosis is most likely to have degenerative calcification of
the
valve. Risk for aortic stenosis increases with age, and congenital valve malformations and rheumatic
fever
are causes in younger patients.
The nurse is caring for a patient who is taking digitalis. The patient complains of
increased thirst, and the nurse observes dry mucous membranes. Which additional finding warrants
the nurse's immediate attention?
a. Sudden, sharp knee pain
b. Blurred vision
c. Epistaxis
d. Chills
ANS: B
Blurred vision, halos around lights, nausea, vomiting and diarrhea, and fatigue are all indicators of
toxicity to digitalis. Assessment is especially important for the dehydrated patient because of the
