Exam (elaborations) NSG 3037 - Med-Surg Practice Test Cardio P2 (Answers & Rationales (NSG 3037)

NSG 3037 Med-surg Practice Test Cardio P2 Congestive Heart Failure 1. 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 CRT less than three (3) seconds. 2. 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? 1. The client will be able to ambulate in the hall by date of discharge. 2. The client will have an audible S1 and S2 with no S3 heard by end of shift. 3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day two (2) of care. 3. 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 the health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the saltshaker from the dinner table. 4. Encourage the client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime. 4. 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. 2. Obtain a pulse oximetry reading. 3. Take the client’s vital signs. 4. Assist the client to a sitting position. 5. 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. 6. 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. 7. 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. 8. 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. 9. The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit (ICU) via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done. 10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain on inspiration and a nonproductive cough. ....