Complex Care Actual preparation test exam
with Thorough and Correct Answers Updated
2024/2025
The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and
possibly death. High-potassium foods, nsaids, and H2-receptor blockers do not pose a risk in
combination with nitrates.
A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic.
Before positioning the patient on the bedside, what should the nurse assess first?
A. Urine output
B. Heart rhythm
C. Breath sounds
D. Blood pressure - correct answer d
The nurse should evaluate the blood pressure before dangling the patient on the bedside
because the blood pressure can decrease as blood pools in the periphery and preload
decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in
the semi-Fowler's position and use other measures to improve gas exchange.
The patient has heart failure (HF) with an ejection fraction of less than 40%. What core
measures should the nurse expect to include in the plan of care for this patient (select all that
apply)?
A. Left ventricular function is documented\
B. Controlling dysrhythmias will eliminate HF
C. Prescription for digoxin (Lanoxin) at discharge
D. Prescription for ACE inhibitor at discharge
E. Education materials about activity, medications, weight monitoring, and what to do if
symptoms worsen - correct answer a, d and e
,The Joint Commission has identified these three core measures for heart failure patients.
Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF.
Prescribing digoxin for all HF patients is no longer done because there are newer effective
drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range
must be maintained.
After having an MI, the nurse notes the patient has jugular venous distention, gained weight,
developed peripheral edema, and has a heart rate of 108/minute. What should the nurse
suspect is happening?
A. ADHF
B. Chronic HF
C. Left-sided HF
D. Right-sided HF - correct answer d
An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral
edema, and increased heart rate are manifestations of right-sided heart failure.
Beyond the first year after a heart transplant, the nurse knows that what is a major cause of
death?
A. Infection
B. Acute rejection
C. Immunosuppression
D. Cardiac vasculopathy - correct answer d
Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac
vasculopathy (accelerated CAD) are the major causes of death. During the first year after
transplant, infection and acute rejection are the major causes of death. Immunosuppressive
therapy will be used for posttransplant management to prevent rejection and increases the
patient's risk of an infection.
The patient with chronic heart failure is being discharged from the hospital. What information
should the nurse emphasize in the patient's discharge teaching to prevent progression of the
disease to ADHF?
, A. Take medications as prescribed
B. Use oxygen when feeling SOB
C. Only ask the physician's office questions
D. Encourage most activity in the morning when rested - correct answer a
The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the
medications as prescribed along with nondrug therapies such as alternating activity with rest will
help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be
used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored
by a care manager or in a transitional program to assess the patient for medication
effectiveness and monitor for patient deterioration and encourage the patient. This nurse
manager can be asked questions or can contact the health care provider if there is evidence of
worsening HF.
When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks
between the R waves of a patient whose rhythm is regular. From these data, the nurse
calculates the patient's heart rate to be
A. 60 bpm
B. 75 bpm
C. 100 bpm
D. 150 bpm - correct answer c
Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks
represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the
nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).
Which statement best describes the electrical activity of the heart represented by measuring the
PR interval on the ECG?
A. The length of time it takes to depolarize the atrium
B. The length of time it takes for the atria to depolarize and repolarize
C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers
with Thorough and Correct Answers Updated
2024/2025
The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and
possibly death. High-potassium foods, nsaids, and H2-receptor blockers do not pose a risk in
combination with nitrates.
A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic.
Before positioning the patient on the bedside, what should the nurse assess first?
A. Urine output
B. Heart rhythm
C. Breath sounds
D. Blood pressure - correct answer d
The nurse should evaluate the blood pressure before dangling the patient on the bedside
because the blood pressure can decrease as blood pools in the periphery and preload
decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in
the semi-Fowler's position and use other measures to improve gas exchange.
The patient has heart failure (HF) with an ejection fraction of less than 40%. What core
measures should the nurse expect to include in the plan of care for this patient (select all that
apply)?
A. Left ventricular function is documented\
B. Controlling dysrhythmias will eliminate HF
C. Prescription for digoxin (Lanoxin) at discharge
D. Prescription for ACE inhibitor at discharge
E. Education materials about activity, medications, weight monitoring, and what to do if
symptoms worsen - correct answer a, d and e
,The Joint Commission has identified these three core measures for heart failure patients.
Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF.
Prescribing digoxin for all HF patients is no longer done because there are newer effective
drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range
must be maintained.
After having an MI, the nurse notes the patient has jugular venous distention, gained weight,
developed peripheral edema, and has a heart rate of 108/minute. What should the nurse
suspect is happening?
A. ADHF
B. Chronic HF
C. Left-sided HF
D. Right-sided HF - correct answer d
An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral
edema, and increased heart rate are manifestations of right-sided heart failure.
Beyond the first year after a heart transplant, the nurse knows that what is a major cause of
death?
A. Infection
B. Acute rejection
C. Immunosuppression
D. Cardiac vasculopathy - correct answer d
Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac
vasculopathy (accelerated CAD) are the major causes of death. During the first year after
transplant, infection and acute rejection are the major causes of death. Immunosuppressive
therapy will be used for posttransplant management to prevent rejection and increases the
patient's risk of an infection.
The patient with chronic heart failure is being discharged from the hospital. What information
should the nurse emphasize in the patient's discharge teaching to prevent progression of the
disease to ADHF?
, A. Take medications as prescribed
B. Use oxygen when feeling SOB
C. Only ask the physician's office questions
D. Encourage most activity in the morning when rested - correct answer a
The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the
medications as prescribed along with nondrug therapies such as alternating activity with rest will
help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be
used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored
by a care manager or in a transitional program to assess the patient for medication
effectiveness and monitor for patient deterioration and encourage the patient. This nurse
manager can be asked questions or can contact the health care provider if there is evidence of
worsening HF.
When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks
between the R waves of a patient whose rhythm is regular. From these data, the nurse
calculates the patient's heart rate to be
A. 60 bpm
B. 75 bpm
C. 100 bpm
D. 150 bpm - correct answer c
Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks
represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the
nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).
Which statement best describes the electrical activity of the heart represented by measuring the
PR interval on the ECG?
A. The length of time it takes to depolarize the atrium
B. The length of time it takes for the atria to depolarize and repolarize
C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers
