NUR 242 MED SURG EXAM 3 LATEST ACTUAL EXAM 180
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |PRE-EVALUATED A+
An older client with a history of congestive heart failure expresses concern about potential exposure to
tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great
deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more
information about the roommate? - CORRECT ANSWER-TB adversely affects older adults with chronic
illness
When the clinic nurse is teaching a group of clients with heart failure (HF) about dietary interventions to
prevent fluid overload, which topic will be included? - CORRECT ANSWER-Use of fresh or frozen
vegetables instead of canned ones / low sodium
Which action would the nurse take first when a client with heart failure has an episode of paroxysmal
nocturnal dyspnea (PND)? - CORRECT ANSWER-Assist the client to sit on the edge of the bed
When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects which
assessment findings? Select all that apply. One, some, or all responses may be correct. - CORRECT
ANSWER-Dependent edema
Swollen hands and fingers
Right upper quadrant discomfort
,The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles.
Which is the priority nursing intervention? - CORRECT ANSWER-Place client in a high-Fowler position.
Which treatment would the nurse anticipate when caring for an infant with heart failure? - CORRECT
ANSWER-Medications that are prescribed for both children and adults
Which feeding education would the nurse provide the parent of a 2-month-old infant with the diagnosis
of heart failure? - CORRECT ANSWER-Feed slowly while allowing time for adequate periods of rest
Which assessment finding would indicate improvement in a 4-month-old infant admitted to the
pediatric unit with a diagnosis of congestive heart failure? - CORRECT ANSWER-Weight loss during next 2
days
The parent of an infant with heart failure questions the necessity of weighing the baby every morning.
Which would the nurse say that this daily information is important in determining? - CORRECT ANSWER-
fluid retention
While auscultating the heart, a health care provider notices S 3 heart sounds in four clients. Which client
is at highest risk for heart failure? - CORRECT ANSWER-Older adult client
Which assessment finding is a late sign of heart failure? - CORRECT ANSWER-Peripheral edema
Heart failure develops in a 4-month-old infant with a congenital heart defect, and the infant exhibits
marked dyspnea at rest. Which assessment finding would the nurse expect in this infant? - CORRECT
ANSWER-Bilateral crackles
Which method would the nurse use to weigh a 2-month-old in heart failure with practitioner orders for
semi-Fowler positioning? - CORRECT ANSWER-Placing the infant in an infant seat, recording the weight,
and then subtracting the weight of the seat
Which early sign of heart failure would the nurse recognize in an infant who has a congenital heart
defect with left-to-right shunting of blood? - CORRECT ANSWER-Increased respiratory rate
, A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin
0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item would the nurse
teach the mother to use when administering the medication? - CORRECT ANSWER-Calibrated syringe
An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value
would the nurse report to the health care provider? - CORRECT ANSWER-Potassium of 3.0 mEq/L (3.0
mmol/L)
A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered
nurse identifies that which items on the client's care plan are appropriate for a licensed practical nurse
(LPN) to perform? Select all that apply. One, some, or all responses may be correct. - CORRECT ANSWER-
Help the client ambulate when required.
Monitor the client's vitals every 30 minutes
Administer adequate oral fluids to the client
The nurse taught a client with heart failure who is scheduled for discharge about how medications, diet,
and exercise improve activity tolerance. During a follow-up visit, the nurse finds that the client has
learned how to adapt his or her exercise prescription to increase activity tolerance. Which theory did the
nurse follow to achieve this positive outcome? - CORRECT ANSWER-Roy's theory
Which intervention would the nurse use after observing that a 6-month-old child lies quietly, rarely
smiles or babbles, and has his basic needs barely met by the primary caregiver, who is a grandparent
with chronic heart failure? - CORRECT ANSWER-Initiate a referral for assessment of home health and
schedule a family conference.
A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1 kg). How
many milliliters of fluid has the client retained? . ___mL - CORRECT ANSWER-2700 ml
An infant with a congenital heart defect is in heart failure and is receiving daily weight measurements.
Which complication of heart failure would daily weights help monitor? - CORRECT ANSWER-Fluid
retention
Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot and
heart failure? - CORRECT ANSWER-Providing small, frequent feedings
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