Which definition best describes left-sided heart failure?
A. Increased volume and pressure develop and result in peripheral edema
B. It can occur when cardiac output remains normal or above normal
C. There is decreased tissue perfusion from poor cardiac output and
pulmonary congestion from increased pressure in the pulmonary vessels
D. It is the percentage of blood ejected from the heart during systole Right
Ans - C. There is decreased tissue perfusion from poor cardiac output and
pulmonary congestion from increased pressure in the pulmonary vessels
When heart failure develops, what is the initial compensatory mechanism of
the heart that maintains cardiac output?
A. Sympathetic stimulation
B. Parasympathetic stimulation
C. Renin-angiotensin-activation system (RAAS)
D. Myocardial hypertrophy Right Ans - A. Sympathetic stimulation
The nurse is taking a history on a patient with recently diagnosed heart
failure. The patient admits to "sometimes have trouble catching my breath"
but is unable to provide more specific details. What question does the nurse
ask to gather more data about the patient's symptoms?
A. "Do you have any medical problems, such as high blood pressure?"
B. "What did your doctor tell you about your diagnosis?"
C. "What was your most strenuous activity in the past week?"
D. "How do you feel about being told that you have heart failure?" Right
Ans - C. "What was your most strenuous activity in the past week?"
The nurse is assessing a patient with left-sided heart failure. Which
assessment findings does the nurse expect to see in this patient? SATA
A. Dependent edema
B. weight loss
C. jugular venous distention
D. hypotension
E. hepatomegaly
F. angina Right Ans - a. dependent edema
C. jugular venous distention
E. hepatomegaly
,Based on the etiology and the main cause of heart failure, which patient has
the greatest need for health promotion measures to prevent heart failure?
A. Patient with Alzheimer's
B. Patient with cystitis
C. Patient with asthma
D. Patient with hypertension Right Ans - D. Patient with hypertension
The nurse is reviewing diagnostic test results for a patient who is
hypertensive. Which laboratory results is an early warning sign of decreased
heart compliance and prompts the nurse to immediately notify the health care
provider?
A. Normal B-type natriuretic peptide
B. Decreased hemoglobin
C. Elevated thyroxine (T4)
D. Presence of microalbuminuria Right Ans - D. Presence of
microalbuminuria
A patient who was admitted for newly diagnosed heart failure is now being
discharged. The nurse instructs the patient and family on how to manage
heart failure at home. What major self-management categories should the
nurse include? SATA
A. Medications
B. Weight
C. Heart transplants
D. Activity
E. Diet
F. What to do when symptoms get worse Right Ans - A. Medications
B. Weight
D. Activity
E. Diet
F. What to do when symptoms get worse
A patient is at risk for heart failure but currently has no official medical
diagnosis. While assessing the patient's lungs, the nurse hears profuse fine
crackles. What does the nurse do next?
A. Report the finding to the health care provider
B. Document the finding as a baseline for later comparison
C. Give the patient low-flow supplemental oxygen
,D. Ask the patient to cough and auscultate the lungs Right Ans - D. Ask the
patient to cough and auscultate the lungs
The home health nurse is evaluating a patient being treated for heart failure.
Which statement by the patient is the best indicator of hope and well-being as
a desired psychological outcome?
A. "I'm taking the medication and following the doctor's orders"
B. "I'm looking forward to dancing with my wife on our wedding anniversary"
C. "I'm planning to go on a long trip; I'll never go back to the hospital again"
D. "I want to thank you for all that you have done. I know you did your best"
Right Ans - B. "I'm looking forward to dancing with my wife on our wedding
anniversary"
The nursing student is assisting in the care of a patient with advanced right-
sided heart failure. In addition to bringing a stethoscope, what additional
piece of equipment does the student bring in order to assess this patient?
A. Tape measure
B. Glasgow Coma Scale
C. Portable Doppler
D. Bladder ultrasound scanner Right Ans - A. Tape measure
A patient with heart failure has inadequate tissue perfusion. Which nursing
interventions are included in the plan of care for this patient? SATA
A. Monitor respiratory rate, rhythm, and quality every 1-4 hours
B. Auscultate breath sounds every 4-8 hours
C. Provide supplemental oxygen to maintain oxygen saturations at 90% or
greater
D. Place the patient in a supine position with pillows under each leg
E. Assist the patient in performing coughing and deep-breathing exercises
every 2 hours
F. Encourage the patient to perform all ADLs even when tired Right Ans - A.
Monitor respiratory rate, rhythm, and quality every 1-4 hours
B. Auscultate breath sounds every 4-8 hours
C. Provide supplemental oxygen to maintain oxygen saturations at 90% or
greater
E. Assist the patient in performing coughing and deep-breathing exercises
every 2 hours
, An older adult patient with heart failure is volume depleted and has a low
sodium level. The health care provider has ordered valsartan, an angiotensin
receptor blocker (ARB). After the initial dose, for what complication does the
nurse carefully monitor in this patient?
A. Hypotension
B. Cough
C. Fluid retention
D. Chest pain Right Ans - A. Hypotension
A patient with heart failure has excessive aldosterone secretion and is
experiencing thirst and continuously asking for water. What instruction does
the nurse give the unlicensed assistive personnel (UAP)?
A. Severely restrict fluid to 500 mL plus output from the previous 24 hours
B. Give the patient as much water as desired to prevent dehydration
C. Restrict fluid to 2 L daily, with accurate intake and output
D. Frequently offer the patient ice chips and moistened toothettes Right
Ans - C. Restrict fluid to 2 L daily, with accurate intake and output
An older adult patient is taking digoxin for treatment of heart failure. What is
the priority nursing action for this patient related to the medication therapy?
A. Give the mediation in conjunction with an antacid
B. Keep the patient on the cardiac monitor and observe for ventricular
dysrhythmias
C. Monitor for early signs of toxicity such as bradycardia on the ECG tracing
D. Advise the patient that there is increased mortality related to toxicity
Right Ans - C. Monitor for early signs of toxicity such as bradycardia on the
ECG tracing
The nurse reviewing the ECG of a patient on digoxin therapy. What early sign
of digitalis toxicity does the nurse look for?
A. Tachycardia
B. Peaked T waves
C. Atrial fibrillation
D. Loss of P waves Right Ans - D. Loss of P waves
A patient is receiving an infusion of nesiritide for treatment of heart failure.
What is the priority nursing assessment while administering this medication?
A. Monitor for hypotension
B. Assess for cardiac dysrhythmias
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