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NUR 3102 HEART FAILURE QUESTION 2021
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NUR 3102 HEART FAILURE QUESTION 2021, HEART FAILURE QUESTION
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?
A. 1. Apical pulse rate of 110 and 4+ pitting edema of feet.
B. 2. Thick white sputum and crackles that clear with cough.
C. 3. The client sleeping with no pillow and eupnea.
D. 4. Radial pulse rate of 90 and capillary refill time <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? The client will:
A. 1. Be able to ambulate in the hall by date of discharge.
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B. 2. Have an audible S1 and S2 with no S3 heard by end of shift.
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C. 3. Turn, cough, and deep breathe every two (2) hours.
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D. 4. Have a pulse oximeter reading of 98% by day two (2) of care.
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3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive
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heart failure. Which interventions should be included in the plan? Select all that apply.
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A. 1. Notify health-care provider of a weight gain of more than one (1) pound in a
week.
B. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac
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glycoside.
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C. 3. Instruct client to remove the saltshaker from the dinner table.
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D. 4. Encourage client to monitor urine output for change in color to become dark.
E. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.
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4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is
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lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which
intervention would the nurse implement first?
A. 1. Sponge the client’s forehead.
B. 2. Obtain a pulse oximetry reading.
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C. 3. Take the client’s vital signs.
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D. 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?
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A. 1. The client’s peripheral pitting edema has gone from 3+ to 4+.
B. 2. The client is able to take the radial pulse accurately.
C. 3. The client is able to perform ADLs without dyspnea.
D. 4. The client has minimal jugular vein distention
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