HEART FAILURE NCLEX EXAM LATEST VERSION
2024-2025 ACTUAL EXAM 120 QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse recognizes that a primary goal for a patient with chronic heart failure is what?
Maximizing cardiac output
Maintaining an ideal body weight
Performing daily aerobic exercises
Maintaining a steady pulse oximetry reading - ANSWER-An increase in cardiac output helps overcome
chronic heart failure, thereby maintaining the blood flow to meet the body's demand. Being overweight
is just one risk factor for chronic heart failure; maintaining ideal body weight may not be a goal for some
patients. Performing daily aerobic exercises may be too strenuous on the heart. There are many risk
factors to consider when determining treatment goals. Pulse oximetry is used to monitor the
effectiveness of oxygen therapy, and achievement of a steady reading is not a practical or primary goal.
p. 746
A patient who underwent cardiac transplantation exhibits signs of acute rejection. The nurse recognizes
that which medication is often used as posttransplantation therapy to prevent this type of response?
Ibuprofen
Metoprolol
Tacrolimus
Acetaminophen - ANSWER-Tacrolimus is a calcineurin that is included in most immunosuppressive
regimens. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID) used to treat pain. Metoprolol is a
beta-blocker that is used to treat hypertension. Acetaminophen is a nonsteroidal antiinflammatory drug
(NSAID) that is used to treat pain and fever. p. 754
A patient with cardiac failure is scheduled to receive sodium nitroprusside. The nurse should monitor
what parameter while administering the drug to the patient?
Blood pressure
Body temperature
Heart rate and pulse rate
,Central venous pressure - ANSWER-Symptomatic hypotension is a major adverse effect of sodium
nitroprusside; therefore, blood pressure is continuously monitored in patients taking sodium
nitroprusside. Body temperature, heart rate, and central venous pressure are not altered due to
administration of this drug. p. 745
The nurse reviews the teaching plan that has been created for a patient with chronic heart failure that is
being discharged from the hospital. The nurse should question which item that is listed on the plan?
Eat small, frequent meals.
Obtain the annual flu vaccine.
Avoid extremes of heat and cold.
Immediately report a weight gain of 5 pounds in 2 days. - ANSWER-The patient should be instructed to
immediately report a weight gain of 3 pounds in 2 days, or 3-5 pounds in a week. Eating small, frequent
meals is a component of the dietary therapy. The patient should be instructed to receive the annual flu
vaccination for health promotion. The patient should be instructed to avoid extremes of heat and cold,
to prevent stress on the heart. P. 751
The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What
is the prioritynursing assessment?
Lung sounds
Facial swelling
Level of anxiety
Intake and output - ANSWER-The priority nursing assessment is auscultation of lung sounds. Excess
fluid volume often leads to pulmonary congestion. ADHF can manifest as pulmonary edema. Facial
swelling is a possible side effect with prescribed renin-angiotensin-aldosterone inhibitors for heart
failure. It is important to assess the patient's anxiety, but it is not the priority. Assessing intake and
output is important for right-sided heart failure.
p. 741
The nurse reviews the laboratory results of a patient with heart failure (HF) who receives a prescription
for digoxin. The nurse decides to withhold the medication based on abnormal findings of what blood
study?
Potassium
Thyroid function tests
,White blood cells (WBCs)
Blood urea nitrogen (B.U.N.) - ANSWER-Low serum potassium enhances the actions of digitalis, causing
a therapeutic dose to reach toxic levels. Similarly, hyperkalemia inhibits the actions of digitalis, resulting
in subtherapeutic dose. Monitor serum potassium levels of all patients taking digitalis. The results of a
B.U.N., WBCs, or thyroid function tests do not affect the nurse's decision to administer or to withhold
digoxin.
p. 748
A patient is diagnosed with left-sided heart failure. The nurse expects what assessment finding?
Orthopnea
Low blood pressure
Pulsating neck veins
Edema in the lower extremities - ANSWER-Orthopnea, difficulty breathing except when sitting or
standing, is a symptom of advanced heart failure, especially left-sided failure. When the heart fails as a
pump, blood backs up into the lungs, causing fluid to leak from the alveolar membrane. As this process
continues, pulmonary edema may develop. Patients may experience hypotension or hypertension,
depending on the severity of the disease. Pulsating neck veins and edema in the lower extremities are
characteristics of right-sided heart failure.
A patient is diagnosed with left ventricular hypertrophy that resulted from untreated hypertension. The
nurse should monitor the patient for symptoms of what condition?
Poor contractility
Less O 2 requirement
Decreased ventricular irritability
Rich coronary arterial circulation - ANSWER-Poor contractility is a complication seen in patients who
have hypertrophy of the cardiac walls. The heart muscle, which undergoes hypertrophy, increases in
muscle mass and cardiac wall thickness, due to overwork and strain. As a result, the hypertrophic heart
muscle exhibits poor contractility over time. Hypertrophic heart muscle is more irritable and, thus, prone
to dysrhythmias. A hypertrophic heart requires more oxygen (O 2) to perform work. Because the tissue
in a hypertrophic heart becomes ischemic more easily, there is poor coronary artery circulation. p. 740
The nurse recalls that symptoms of right-sided heart failure are caused by what condition?
Decreased preload
, Increased cardiac output
Fluid congestion in the lungs
Systemic venous congestion - ANSWER-Systemic venous congestion
The symptoms of right-sided heart failure are caused by the backup of blood into the venous system.
Fluid congestion in the lungs is a symptom of left-sided heart failure. Decreased preload is not correct;
preload in right-sided heart failure is increased. Increased cardiac output is not correct; cardiac output is
decreased in right-sided heart failure
An echocardiogram for a patient indicates enlarged ventricles of the heart. The nurse caring for the
patient understands that this condition has occurred as a result of a chronic condition. What could be
the cause of the cardiac dilation?
Increased heart rate
Increased muscle thickness
Elevated pressure in the ventricles
Increased release of catecholamine - ANSWER-Elevated pressure in the ventricles
Cardiac dilation is an enlargement of the heart chambers, usually the ventricles; it occurs when pressure
in the heart chambers is elevated over time. Hypertrophy is an increase in the muscle mass and
thickness of the cardiac wall in response to overwork and strain. When the sympathetic nervous system
activation is increased, there is an increased release of catecholamines, which results in an increased
heart rate.
p. 740
The nurse is caring for a patient with chronic heart failure and atrial fibrillation that takes digoxin and a
thiazide diuretic. Which statement made by the patient indicates that the patient is experiencing a
complication related to the medication?
"My ankles are still slightly swollen."
"I have to urinate a lot after I take those pills!"
"I'm not really hungry for lunch. I feel so nauseated and tired."
"I check my heart rate regularly. It is usually 80-90 beats per minute." - ANSWER-"I'm not really hungry
for lunch. I feel so nauseated and tired."
Drug therapy with digoxin and potassium-losing diuretics (thiazides or loop diuretics) may lead to
hypokalemia. The presence of hypokalemia while the patient is on digoxin may lead to digoxin toxicity.
Signs of early digoxin toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and
2024-2025 ACTUAL EXAM 120 QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse recognizes that a primary goal for a patient with chronic heart failure is what?
Maximizing cardiac output
Maintaining an ideal body weight
Performing daily aerobic exercises
Maintaining a steady pulse oximetry reading - ANSWER-An increase in cardiac output helps overcome
chronic heart failure, thereby maintaining the blood flow to meet the body's demand. Being overweight
is just one risk factor for chronic heart failure; maintaining ideal body weight may not be a goal for some
patients. Performing daily aerobic exercises may be too strenuous on the heart. There are many risk
factors to consider when determining treatment goals. Pulse oximetry is used to monitor the
effectiveness of oxygen therapy, and achievement of a steady reading is not a practical or primary goal.
p. 746
A patient who underwent cardiac transplantation exhibits signs of acute rejection. The nurse recognizes
that which medication is often used as posttransplantation therapy to prevent this type of response?
Ibuprofen
Metoprolol
Tacrolimus
Acetaminophen - ANSWER-Tacrolimus is a calcineurin that is included in most immunosuppressive
regimens. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID) used to treat pain. Metoprolol is a
beta-blocker that is used to treat hypertension. Acetaminophen is a nonsteroidal antiinflammatory drug
(NSAID) that is used to treat pain and fever. p. 754
A patient with cardiac failure is scheduled to receive sodium nitroprusside. The nurse should monitor
what parameter while administering the drug to the patient?
Blood pressure
Body temperature
Heart rate and pulse rate
,Central venous pressure - ANSWER-Symptomatic hypotension is a major adverse effect of sodium
nitroprusside; therefore, blood pressure is continuously monitored in patients taking sodium
nitroprusside. Body temperature, heart rate, and central venous pressure are not altered due to
administration of this drug. p. 745
The nurse reviews the teaching plan that has been created for a patient with chronic heart failure that is
being discharged from the hospital. The nurse should question which item that is listed on the plan?
Eat small, frequent meals.
Obtain the annual flu vaccine.
Avoid extremes of heat and cold.
Immediately report a weight gain of 5 pounds in 2 days. - ANSWER-The patient should be instructed to
immediately report a weight gain of 3 pounds in 2 days, or 3-5 pounds in a week. Eating small, frequent
meals is a component of the dietary therapy. The patient should be instructed to receive the annual flu
vaccination for health promotion. The patient should be instructed to avoid extremes of heat and cold,
to prevent stress on the heart. P. 751
The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What
is the prioritynursing assessment?
Lung sounds
Facial swelling
Level of anxiety
Intake and output - ANSWER-The priority nursing assessment is auscultation of lung sounds. Excess
fluid volume often leads to pulmonary congestion. ADHF can manifest as pulmonary edema. Facial
swelling is a possible side effect with prescribed renin-angiotensin-aldosterone inhibitors for heart
failure. It is important to assess the patient's anxiety, but it is not the priority. Assessing intake and
output is important for right-sided heart failure.
p. 741
The nurse reviews the laboratory results of a patient with heart failure (HF) who receives a prescription
for digoxin. The nurse decides to withhold the medication based on abnormal findings of what blood
study?
Potassium
Thyroid function tests
,White blood cells (WBCs)
Blood urea nitrogen (B.U.N.) - ANSWER-Low serum potassium enhances the actions of digitalis, causing
a therapeutic dose to reach toxic levels. Similarly, hyperkalemia inhibits the actions of digitalis, resulting
in subtherapeutic dose. Monitor serum potassium levels of all patients taking digitalis. The results of a
B.U.N., WBCs, or thyroid function tests do not affect the nurse's decision to administer or to withhold
digoxin.
p. 748
A patient is diagnosed with left-sided heart failure. The nurse expects what assessment finding?
Orthopnea
Low blood pressure
Pulsating neck veins
Edema in the lower extremities - ANSWER-Orthopnea, difficulty breathing except when sitting or
standing, is a symptom of advanced heart failure, especially left-sided failure. When the heart fails as a
pump, blood backs up into the lungs, causing fluid to leak from the alveolar membrane. As this process
continues, pulmonary edema may develop. Patients may experience hypotension or hypertension,
depending on the severity of the disease. Pulsating neck veins and edema in the lower extremities are
characteristics of right-sided heart failure.
A patient is diagnosed with left ventricular hypertrophy that resulted from untreated hypertension. The
nurse should monitor the patient for symptoms of what condition?
Poor contractility
Less O 2 requirement
Decreased ventricular irritability
Rich coronary arterial circulation - ANSWER-Poor contractility is a complication seen in patients who
have hypertrophy of the cardiac walls. The heart muscle, which undergoes hypertrophy, increases in
muscle mass and cardiac wall thickness, due to overwork and strain. As a result, the hypertrophic heart
muscle exhibits poor contractility over time. Hypertrophic heart muscle is more irritable and, thus, prone
to dysrhythmias. A hypertrophic heart requires more oxygen (O 2) to perform work. Because the tissue
in a hypertrophic heart becomes ischemic more easily, there is poor coronary artery circulation. p. 740
The nurse recalls that symptoms of right-sided heart failure are caused by what condition?
Decreased preload
, Increased cardiac output
Fluid congestion in the lungs
Systemic venous congestion - ANSWER-Systemic venous congestion
The symptoms of right-sided heart failure are caused by the backup of blood into the venous system.
Fluid congestion in the lungs is a symptom of left-sided heart failure. Decreased preload is not correct;
preload in right-sided heart failure is increased. Increased cardiac output is not correct; cardiac output is
decreased in right-sided heart failure
An echocardiogram for a patient indicates enlarged ventricles of the heart. The nurse caring for the
patient understands that this condition has occurred as a result of a chronic condition. What could be
the cause of the cardiac dilation?
Increased heart rate
Increased muscle thickness
Elevated pressure in the ventricles
Increased release of catecholamine - ANSWER-Elevated pressure in the ventricles
Cardiac dilation is an enlargement of the heart chambers, usually the ventricles; it occurs when pressure
in the heart chambers is elevated over time. Hypertrophy is an increase in the muscle mass and
thickness of the cardiac wall in response to overwork and strain. When the sympathetic nervous system
activation is increased, there is an increased release of catecholamines, which results in an increased
heart rate.
p. 740
The nurse is caring for a patient with chronic heart failure and atrial fibrillation that takes digoxin and a
thiazide diuretic. Which statement made by the patient indicates that the patient is experiencing a
complication related to the medication?
"My ankles are still slightly swollen."
"I have to urinate a lot after I take those pills!"
"I'm not really hungry for lunch. I feel so nauseated and tired."
"I check my heart rate regularly. It is usually 80-90 beats per minute." - ANSWER-"I'm not really hungry
for lunch. I feel so nauseated and tired."
Drug therapy with digoxin and potassium-losing diuretics (thiazides or loop diuretics) may lead to
hypokalemia. The presence of hypokalemia while the patient is on digoxin may lead to digoxin toxicity.
Signs of early digoxin toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and
