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Exam 3 v1: NUR242/ NUR 242 | Question and
Answers| Latest 2025/ 2026 Update | Medical –
Surgical Nursing Concepts | 100% Verified Solutions |
GRADED A - Galen
Question:
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? Answer: TB adversely affects older adults with chronic illness
Question:
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? Answer: Use of fresh or frozen vegetables instead of canned ones / low sodium
Question:
Which action would the nurse take first when a client with heart failure has an episode of paroxysmal nocturnal dyspnea (PND)? Answer: Assist the client to sit on the edge of the bed
Question:
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. Answer: Dependent edema Swollen hands and fingers Right upper quadrant discomfort
Question:
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? Answer: Place client in a high-Fowler position.
Question:
Which treatment would the nurse anticipate when caring for an infant with heart failure? Answer: Medications that are prescribed for both children and adults
Question:
Which assessment finding is a late sign of heart failure? Answer: Peripheral edema
Question:
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? Answer: Bilateral crackles
Question:
Which method would the nurse use to weigh a 2 - month-old in heart failure with practitioner orders for semi-Fowler positioning? Answer: Placing the infant in an infant seat, recording the weight, and then subtracting the weight of the seat
Question:
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?
Answer: Increased respiratory rate
Question:
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? Answer: Calibrated syringe
Question:
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? Answer: Potassium of 3.0 mEq/L (3.0 mmol/L)
Question:
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.
Answer: 2700 ml
Question:
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? Answer: Fluid retention
Question:
Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot and heart failure? Answer: Providing small, frequent feedings
Question:
The nurse provides teaching to a client who is being discharged after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor for which indication of right-sided heart failure? Answer: Weight gain
Question:
When a client with heart failure reports frequent sudden waking during the night with shortness of breath, how will the nurse document this finding? Answer: Paroxysmal nocturnal dyspnea
Question:
The nurse explains to a pregnant client with a class II heart failure that in pregnancy the cardiac system is most compromised during which time? Answer: First 2 days after the birth
Question:
Which sign would indicate possible heart failure in a client with heart disease in the immediate postpartum period? Answer: Tachypnea
Question:
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day? Answer:
Decreased edema Decreased pulse rate
Question:
A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin? Answer: Bradycardia
Question:
A health care provider prescribes milrinone for a client with congestive heart failure. Which action would the nurse perform first? Answer: Have the prescription, dosage calculations, and pump settings checked by a second nurse
Question:
Which care plan would the nurse implement for an infant admitted to the pediatric unit with the diagnosis of heart failure? Answer: Offer the infant small, frequent feedings
Question:
Which parent education would the nurse provide as rationale for gavage feedings in an infant with congestive heart failure? Answer: The energy that would have been expended on suckling is conserved
Question:
Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider? Answer: Premature ventricular contractions
Question:
Which statement made by the nursing student requires correction regarding the effect of applying the Roy adaptation model on improved functional status in clients with heart failure? Answer: Use of literature resources supports practical-based nursing interventions."
Question:
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
Irregular pulse
Question:
Which action would the nurse take first when a client who has heart failure reports fatigue and has an increase in heart rate from 90 beats/minute to 120 beats/minute while ambulating? Answer: Have the client sit down and rest
Question:
When the home care nurse calls to make an appointment for the initial visit with a client who has heart failure, the client reports that many family members are visiting today and requests that the nurse wait a week for the appointment. Which response by the nurse is best? Answer: Tell the client that it might be helpful to talk with family members during the initial visit.
Question:
Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse? Answer: Oxygen saturation 86%
Question:
When a client is diagnosed with left-sided congestive heart failure, which assessment findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. Answer: Dyspnea Crackles Frequent cough
Question:
When assessing a client with chronic heart failure, which clinical finding would the nurse expect to find? Answer: Dependent edema in the evening
Question:
When a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32 breaths/minute, which action would the nurse take first? Answer: Elevate the head of the bed to 75 degrees.
Question:
Auscultate breath sounds.
Question:
Which statement by a client who is seen for follow-up in the heart failure clinic is most important for the nurse to communicate to the health care provider? Answer: "I wake up at night short of breath"
Question:
A client with heart failure reports waking suddenly and feeling short of breath during the night. How will the nurse document this information? Answer: Paroxysmal nocturnal dyspnea
Question:
When a client with a history of heart failure on daily weights has a 4-pound (1.8- kilogram) weight gain since the previous day, which action would the nurse take next? Perform a head-to-toe assessment. Answer:
Question:
When caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 beats/minute, and bilateral lung crackles, which prescribed action would the nurse question? Answer: Infuse normal saline at 100 mL/h
Question:
When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb (2.7 kg), which nursing action has the highest priority? Answer: Listen to the client's breath sounds
Question:
When caring for a client with heart failure, which type of lung sounds would the nurse expect to hear? Answer: Crackles
Question:
When reviewing laboratory results for a client with heart failure who has been receiving furosemide daily, the nurse notes a blood urea nitrogen (BUN) of 42 mg/dL (15.2 mmol/L) and a creatinine of 1.1 mg/dL (97 mcmol/L). Which action by the nurse is a priority? Answer:
Coughing at night Difficulty breathing
Question:
Which medication prescribed for a client with an acute episode of heart failure would the nurse question? Answer: Beta blocker
Question:
When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? Answer: Weighing the client
Question:
Which statement by a client is consistent with a diagnosis of heart failure? Answer: "I have trouble breathing when I climb a flight of stairs.
Question:
Which finding would the nurse expect when caring for a client with right-sided heart failure? Answer: Distended neck veins
Question:
When the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure, the client becomes irritable and asks why bed rest is needed. Which response by the nurse is best? Answer: Rest reduces the amount of work your heart has to do right now."
Question:
For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. Answer: Unusual fatigue Dependent edema Nocturnal dyspnea
Question:
